Inpatient Coding Specialist II (Remote)

LE0010 Stanford Health Care; United States; Remote; USD 91,000 - 103,000; Full time

Job summary

Stanford Health Care is seeking an Inpatient Coding Specialist II to review medical records and assign ICD-10-CM/PCS codes, enabling correct MS-DRG/APR-DRG placement. The role ensures accurate POA indicators and compliant discharge dispositions.

The position requires RHIA/RHIT/CCS credentials, experience with Epic and 3M tools, and adherence to CMS and UHDDS standards. Strong communication and independent work style are essential.

Qualifications

• Proficiency in ICD-10-CM/PCS coding for inpatient records.
• Experience with MS-DRG/APR-DRG assignment and abstracting data.
• Knowledge of UHDDS standards and AHA guidelines.
• Familiarity with CMS requirements and CCI edits.
• Proficiency with coding software and reference materials.

Responsibilities

• Review medical record documentation and assign ICD-10 diagnosis and procedure codes.
• Determine MS-DRG/APR-DRG classifications and discharge disposition.
• Abstract data per facility specifications for reimbursement.
• Collaborate with CDSs and medical staff to ensure documentation completeness.
• Maintain quality and productivity standards with minimal supervision.
• Stay current with CMS requirements and coding initiatives.

Skills

ICD-10-CM/PCS coding

MS-DRG/APR-DRG

UHDDS standards

CMS compliance

3M CDIS/Epic

Education

RHIA - Registered Health Information Administrator

RHIT - Registered Health Information Technician

CCS - Certified Coding Specialist

Tools

Epic

3M Encoder

3M Audit Expert

3M CDIS

Job description

Day - 08 Hour (United States of America) This is a Stanford Health Care job.

A Brief Overview

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. This position codes the majority of patient types of inpatient records, including more complex cases such as Intensive Care. Follows the Official Guidelines for Coding and Reporting, the American Health Information Management Association (AHIMA) Standards of Ethical Coding, as well as all American Hospital Association (AHA) Coding Clinic guidance. Follows Stanford Health Care policies and procedures and maintains required quality and productivity standards. Reviews, abstracts and assigns accurate and ethical ICD-10-CM/PCS codes to inpatient services. Ensures compliance with third party, State and Federal regulations. Reviews, analyzes and abstracts physician/other documentation for diagnoses, procedures, and other services provided. Obtains missing information and/or clarifies existing information. Completes volume of work from work queues per departmental productivity standards. Groups codes and completed product into payment group. Analyzes information for optimal and approprite reimbursement. Ensures compliance with all appropriate coding, billing and data collection regulations and procedures. Uses appropriate software to validate information. Utilizes Epic, 3M Coding and Reimbursement System (Encoder), 3M CDIS, 3M Audit Expert, MS Office, and other software as appropriate to compile and validate medical information.

What you will do

Reviews medical record documentation and accurately assigns appropriate ICD-10 diagnosis and procedure codes, leading to the assignment of the correct Medicare Severity-Diagnosis Related Group (MS-DRG) or All Patient Refined Diagnosis Related Group (APR-DRG). The Inpatient Coding Specialist II is responsible for verification of the patient's discharge disposition, assignment of the correct sources of admission for state regulation reporting purposes, and ensuring the appropriate present on admission (POA) indicators are assigned to each code. The assigned codes must support the reason for the visit that is documented by the provider in order to support the care provided. Correctly abstracts required data per facility specifications. Responsible for monitoring Discharged Not Billed accounts, and as a team, ensuring timely, compliant processing of inpatient accounts through the revenue cycle. Collaborates with Clinical Documentation Specialists (CDSs) and members of the medical staff to ensure completeness of documentation in the medical records so that appropriate codes, and, ultimately, the correct Diagnosis Related Group (DRG) may be assigned. Responsible for ensuring accuracy and maintaining established quality and productivity standards. Demonstrates a high degree of independence in performance of responsibilities, working effectively without direct supervision. Exhibits strong time management, problem solving and communication skills. Possesses critical thinking, good judgment and decision making skills. Demonstrates excellent written and oral communication skills. Remains abreast of current Centers for Medicare and Medicaid Services (CMS) requirements as well as Correct Coding Initiative (CCI) edits, Hospital Acquired Conditions (HACs), Patient Safety Indicators (PSIs), and when applicable, National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs,) including the addition of appropriate modifiers to ensure a clean claim the first time through. Maintains competency and accuracy while utilizing tools of the trade such as the 3M encoder, 3M Audit Expert process (3M AES), 3M Clinical Documentation Improvement System (3M CDIS) and abstracting systems, as well as all reference materials. Follows all established Stanford Health Care policies and procedures. Attends required system, hospital and departmental meetings and educational sessions as established by leadership, as well as completion of required annual learning programs, to ensure continued education and growth.

Education Qualifications

High School Diploma or GED equivalent

Experience Qualifications

Five (5) years of progressively responsible and directly related work experience

Required Knowledge, Skills and Abilities

• Successful completion of the Coder Proficiency Exam (pre-hire)
• Ability to adapt to and deal with change and ambiguity
• Ability to plan, organize, prioritize, work independently and meet deadlines
• Ability to comply with the American Health Information Management Association’s Code of Ethics and Standards and apply Uniform Hospital Discharge Data Set (UHDDS) standards
• Ability to establish and maintain effective working relationships
• Ability to manage, organize, prioritize, multi-task and adapt to changing priorities
• Ability to solve technical and non-technical problems
• Ability to utilize the ICD-10-CM/PCS and CPT-4 coding conventions to code medical record entries; abstract information from medical records; read medical record documentation; assign accurate codes for grouping of MS-DRGs and APR-DRGs
• Ability to work effectively through and with others
• Knowledge of diagnosis/procedure DRG grouping schemes such as MS-DRGs and APR-DRGs
• Knowledge of health information systems for computer application to medical records
• Ability to foster effective working relationships and build consensus
• Ability to work effectively with individuals at all levels of the organization
• Knowledge of CCI (Correct Coding Initiatives) and CMS compliance issues
• Knowledge of computer systems and software used in functional area
• Knowledge of standards and regulations pertaining to the maintenance of patient medical records; medical records coding systems; medical terminology; anatomy and physiology and study of diseases

Licenses and Certifications

• RHIA - Registered Health Information Administrator
• RHIT - Registered Health Information Technician
• CCS - Certified Coding Specialist

These principles apply to ALL employees

SHC Commitment to Providing an Exceptional Patient & Family Experience 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 of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery. You will do this by executing against our three experience pillars, from the patient and family’s perspective: Know Me: Anticipate my needs and status to deliver effective care Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer

Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale

Generally starting at $66.10 - $74.44 per hour The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage. At Stanford Health Care, we seek to provide patients with the very best in diagnosis and treatment, with outstanding quality, compassion and coordination. With an unmatched track record of scientific discovery, technological innovation and translational medicine, Stanford Medicine physicians are pioneering leading edge therapies today that will change the way health care is delivered tomorrow. As part of our spirit of discovery, we also leverage our deep relationships with luminary Silicon Valley companies to develop new ways to deliver preeminent patient care.

Locations

Stanford Health Care