Role Description
This position requires review of medical record documentation to accurately assign International Classification of Diseases (ICD-10-CM/PCS), as well as assignment of the Medicare Severity Diagnosis Related Group (MS-DRG) / All Patient Refined - Diagnosis Related Group (APR-DRG) and abstracts specific data elements for each account in compliance with federal and state regulations. The Inpatient Coding Specialist II is responsible for:
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Reviewing medical record documentation and accurately assigning appropriate ICD-10 diagnosis and procedure codes.
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Verifying the patient's discharge disposition and ensuring appropriate present on admission (POA) indicators are assigned.
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Correctly abstracting required data per facility specifications.
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Monitoring Discharged Not Billed accounts to ensure timely, compliant processing of inpatient accounts.
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Collaborating with Clinical Documentation Specialists (CDSs) and medical staff to ensure completeness of documentation.
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Ensuring accuracy and maintaining established quality and productivity standards.
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Demonstrating independence in performance of responsibilities.
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Exhibiting strong time management, problem solving, and communication skills.
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Maintaining competency and accuracy while utilizing tools such as the 3M encoder and abstracting systems.
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Attending required meetings and educational sessions for continued education and growth.
Qualifications
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High School Diploma or GED equivalent.
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Five (5) years of progressively responsible and directly related work experience.
Requirements
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Successful completion of the Coder Proficiency Exam (pre-hire).
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Ability to adapt to and deal with change and ambiguity.
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Ability to plan, organize, prioritize, work independently and meet deadlines.
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Ability to comply with the American Health Information Management Associationβs Code of Ethics and Standards.
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Ability to establish and maintain effective working relationships.
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Ability to manage, organize, prioritize, multi-task and adapt to changing priorities.
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Ability to solve technical and non-technical problems.
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Ability to utilize the ICD-10-CM/PCS and CPT-4 coding conventions.
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Knowledge of diagnosis/procedure DRG grouping schemes such as MS-DRGs and APR-DRGs.
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Knowledge of health information systems for computer application to medical records.
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Knowledge of CCI (Correct Coding Initiatives) and CMS compliance issues.
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Knowledge of standards and regulations pertaining to the maintenance of patient medical records.
Benefits
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Base Pay Scale: Generally starting at $66.10 - $74.44 per hour.
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The salary of the finalist selected for this role will be set based on various factors, including internal equity, experience, education, specialty, and training.
Company Description
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all patients, families, and towards each other.
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Know Me: Anticipate my needs and status to deliver effective care.
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Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health.
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Coordinate for Me: Own the complexity of my care through coordination.