Inpatient Coding Specialist II (Remote)

Stanford Health Care•Hubley Township, PA

6d•$66 - $74•Remote

About The Position

The Inpatient Coding Specialist II reviews inpatient medical records and assigns accurate ICD-10-CM/PCS diagnosis and procedure codes, abstracts required data, and groups completed codes into the appropriate MS-DRG or APR-DRG. The role covers most inpatient patient types, including complex cases such as Intensive Care, and ensures codes support the provider-documented reason for the visit and care provided. Responsibilities include verifying discharge disposition, assigning sources of admission for state reporting, and applying present-on-admission indicators. The specialist monitors Discharged Not Billed accounts and supports timely, compliant processing of inpatient accounts through the revenue cycle. They collaborate with Clinical Documentation Specialists and medical staff to resolve documentation needs, analyze information for appropriate reimbursement, and maintain coding accuracy, quality, and productivity standards. The position requires independent work, sound judgment, effective communication, and ongoing attention to CMS requirements, coding guidance, and applicable regulations. The role uses Epic, 3M Coding and Reimbursement System (Encoder), 3M CDIS, 3M Audit Expert, abstracting systems, MS Office, and other appropriate software and reference materials. The specialist follows official coding guidelines, AHIMA ethical coding standards, AHA Coding Clinic guidance, and Stanford Health Care policies and procedures. Required system, hospital, and departmental meetings, educational sessions, and annual learning programs support continued education and growth.

Requirements

High school diploma or GED equivalent.
Five years of progressively responsible and directly related work experience.
Successful completion of the pre-hire Coder Proficiency Exam.
One of the following certifications: RHIA, RHIT, or CCS.
Ability to apply AHIMA's Code of Ethics and Standards and UHDDS standards.
Ability to use ICD-10-CM/PCS and CPT-4 coding conventions, read and abstract medical records, and assign accurate codes for MS-DRG and APR-DRG grouping.
Knowledge of MS-DRG and APR-DRG grouping schemes, health information systems, CCI and CMS compliance issues, and relevant computer systems and software.
Knowledge of medical record standards and regulations, coding systems, medical terminology, anatomy and physiology, and diseases.
Ability to plan, organize, prioritize, multitask, adapt to change and ambiguity, work independently, and meet deadlines.
Ability to solve technical and non-technical problems and exercise critical thinking, judgment, and decision-making.
Ability to establish effective working relationships, build consensus, and work effectively with people at all organizational levels.
Strong written and oral communication skills.

Responsibilities

Review inpatient medical record documentation and assign accurate ICD-10 diagnosis and procedure codes, including codes leading to the appropriate MS-DRG or APR-DRG.
Verify patient discharge disposition, assign admission sources for state reporting, and apply present-on-admission indicators.
Abstract required data according to facility specifications.
Monitor Discharged Not Billed accounts and help ensure timely, compliant processing of inpatient accounts through the revenue cycle.
Collaborate with Clinical Documentation Specialists and medical staff to address documentation completeness and support appropriate coding and DRG assignment.
Maintain established accuracy, quality, and productivity standards.
Stay current with CMS requirements, CCI edits, HACs, PSIs, and applicable NCDs and LCDs, including appropriate modifiers to support clean claims.
Use coding, audit, clinical documentation, abstracting, and other software tools and reference materials to validate information.
Follow Stanford Health Care policies and procedures, official coding guidance, and ethical coding standards.
Attend required meetings and educational sessions and complete annual learning programs.