Requirements
- High School Diploma or GED equivalent
- Five (5) years of progressively responsible and directly related work experience
- 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
- RHIA - Registered Health Information Administrator or RHIT - Registered Health Information Technician or CCS - Certified Coding Specialist
Additional Information
- 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.
