PT 0.6 Coder

LE0030 Stanford Health Care Tri-Valley; Pleasanton (CA); On-site; USD 54,000 - 68,000; Full time

Job summary

Stanford Health Care Tri-Valley in Pleasanton, CA seeks an experienced Medical Records Coder to accurately code and abstract inpatient and outpatient records using ICD-9-CM and CPT4 guidelines, supporting reimbursement, research, and audits.

The role requires OSHPD-compliant data abstraction, high accuracy, and educating providers on documentation. RHIA/RHIT/CCS credentials with at least three years of coding experience and familiarity with 3M encoder are preferred.

Qualifications

• Demonstrates ability to code with ICD-9 CM and CPT4 accurately
• Abstracts data elements per OSHPD and department guidelines
• Maintains high accuracy in coding and data abstraction

Responsibilities

• Code principal and secondary diagnoses and procedures per ICD-9-CM and CPT4
• Abstract data from medical charts for OSHPD and research
• Maintain weekly production reports and support QA initiatives
• Educate providers and staff on documentation requirements
• Precept new staff on coding standards
• Work collaboratively across multiple service lines

Skills

ICD-9-CM coding

CPT4 coding

Medical terminology

Abstracting data

Education

RHIA/RHIT/CCS credential

Medical Terminology & Physiology & Anatomy

Tools

3M encoder

Job description

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Rotating - 08 Hour (United States of America)

This is a Stanford Health Care Tri-Valley job.

A Brief Overview

Assumes responsibility for accurately coding and abstracting medical records of discharged patients for reimbursement purposes and to establish statistical indices and data sources used for research studies, surveys, and medical audits and special reports.

Responsible for evaluating information in the medical record for completeness, consistency and accuracy.

Has working knowledge of all work aspects of the Health Information Management Department and its Responsibilities.

Required to have technical, in-depth understanding of the substantive contents of the medial record including a comprehensive grasp of a wide variety of specialized medical terminology, testing and treatment relationships and sequences and detailed knowledge and skill in the current version of the International Classification of Diseases (ICD-9-CM) and CPT4 coding systems and structure.

Locations

Stanford Health Care Tri-Valley

What you will do

Codes a wide variety of principal and secondary diagnoses and procedures according to the latest adaptation of the International Classification of Diseases (ICD-9-CM) and CPT4 coding and according to official coding guidelines and UHDDS definitions.

Relies of knowledge of anatomy, physiology, disease processes, and medical terminology in searching the medical chart in order to complete properly sequence the coding of diagnoses and procedures and to determine proper codes for diagnoses and procedures not clearly listed in the ICD-9-CM code books.

Assigns CPT4 procedure codes on appropriate Medicare and Medi-Cal inpatient charts and outpatient charts.

Abstracts data elements on-line according to department guidelines, abstracting requirements, hospital and department needs.

Abstracts pertinent data from medical charts according to criteria established by the office of Statewide Health Planning and Development (OSHPD), Medical Staff for individual physicians for various studies.

Abstracts information from medical charts for statistical indexing and preparation of summary reports to various agencies.

Maintains a tally of work production and submits weekly reports to supervisor.

Accepts responsibility for performing special studies and related tasks as delegated by the Supervisor.

Assists in continually upgrading the Quality Improvement efforts of the Health Information Management Department by identifying discrepancies found in work procedures, participating in problem solving methods and cooperating in the implementation of corrective action, if necessary.

Participates in departmental programs for continuing education, health and safety programs and fire safety plans.

Performs other related duties as requested by Supervisor.

Consistently demonstrates a team player attitude.

Maintains harmonious working relationships within the department and outside the department, including interaction with the Medical Staff.

Works efficiently and effectively throughout the workday.

Attendance: No more than 3 unscheduled PTO requests within a 6 month period. Less than 3 request to leave early or come in late within a 6 month period.

Education Qualifications Credentials (or eligible)

as RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist) with successful completion of accredited course in coding with ICD-9-CM and CPT4 coding systems

Required Successful completion of accredited courses in Medical Terminology and Physiology and Anatomy and disease processes

Experience Qualifications

Three (3) years previous experience

Required Knowledge, Skills and Abilities LEVEL REQUIREMETNS

Demonstrates ability and proficiency to be productive while maintaining a high level of accuracy in coding with ICD-9 CM and CPT4 systems and in abstracting information

Expanded knowledge and ability to support multiple departments (i.e. CCL, GI, OR)

Educates providers and staff on documentation requirements

Precepts new staff and physicians on documentation requirements

Supports two (2) or more service lines

REQUIRED CERTIFICATIONS

• CCS (Certified Coding Specialist) or CIRCC (Certified Interventional Radiology Cardiovascular Coder) or CPC (Certified Professional Coder) Successful completion of ICD - 9 CM (or most current) and CPT 4 coding systems
• Successful completion of accredited courses in Medical Terminology, physiology, anatomy and diseases processes
• Successful completion coding test at a minimal level of 90% Knowledge and experience in use of 3M encoder preferred
• Licenses and Certifications CCS - Certified Coding Specialist required and CPC and/or CCSP - Certified Professional Coder or ICD10 CERTIFICATION

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 $39.56 - $49.45 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.

Few great things are ever truly done alone. Performing at the highest level and achieving your best requires support and a team of dedicated people focused on doing amazing things every day.

If that sounds like the environment you’ve been looking for, then we’ve got a place for you.

Stanford Health Care - Tri-Valley is seeking outstanding allied health, business, and nursing professionals to join our world-class team.

Supported by a devoted staff and a progressive culture, we offer the freedom, opportunity, and respect your talent deserves.

Not every job offers this; but here, we don’t know how to work any other way.

We invite you to join our team!