PT 0.6 Coder

Stanford Health Care Tri-Valley•Pleasanton, CA

10h•$40 - $49

About The Position

The Coder accurately codes and abstracts medical records of discharged patients for reimbursement and to establish statistical indices and data sources used for research studies, surveys, medical audits, and special reports. The role evaluates medical records for completeness, consistency, and accuracy and requires technical knowledge of medical-record content, medical terminology, testing and treatment relationships, and ICD and CPT coding systems. The Coder supports Health Information Management work by coding diagnoses and procedures, abstracting information for reporting and statistical purposes, and contributing to quality improvement and continuing education. The role also educates providers and staff on documentation requirements, supports multiple service lines, and works collaboratively with department colleagues and the Medical Staff.

Requirements

Three years of previous experience.
Credential, or eligibility for a credential, as RHIA, RHIT, or CCS, with successful completion of an accredited coding course covering ICD-9-CM and CPT4 coding systems.
Successful completion of accredited courses in medical terminology, physiology, anatomy, and disease processes.
Required CCS, CIRCC, or CPC certification; the licenses and certifications section additionally lists CCS as required and CPC and/or CCSP or ICD10 certification.
Successful completion of ICD-9-CM (or most current version) and CPT4 coding systems training.
Successful completion of a coding test at a minimum score of 90%.
Ability to code productively and accurately using ICD-9-CM and CPT4 systems and abstract information.
Expanded knowledge and ability to support multiple departments, such as CCL, GI, and OR.
Ability to educate providers and staff and precept new staff and physicians on documentation requirements.
Ability to support two or more service lines.

Nice To Haves

Knowledge and experience using the 3M encoder.

Responsibilities

Code principal and secondary diagnoses and procedures according to current ICD coding adaptations, CPT4, official coding guidelines, and UHDDS definitions.
Use knowledge of anatomy, physiology, disease processes, and medical terminology to review charts, sequence codes, and determine appropriate codes when diagnoses or procedures are not clearly listed in code books.
Assign CPT4 procedure codes to applicable Medicare and Medi-Cal inpatient and outpatient charts.
Abstract data elements online according to department guidelines, abstracting requirements, and hospital and department needs.
Abstract chart data according to OSHPD criteria and Medical Staff requirements for physician-specific studies.
Abstract information from medical charts for statistical indexing and summary reports to agencies.
Track work production and submit weekly reports to the supervisor.
Perform special studies and related tasks as delegated by the supervisor.
Identify work-procedure discrepancies, participate in problem solving, and cooperate in implementing corrective action as part of departmental quality improvement.
Participate in continuing education, health and safety programs, and fire safety plans.
Maintain collaborative working relationships within and outside the department, including with the Medical Staff.
Work efficiently throughout the workday and meet the stated attendance expectations.
Perform other related duties as requested by the supervisor.
Educate providers and staff on documentation requirements and precept new staff and physicians on those requirements.
Support two or more service lines and multiple departments.