Inpatient Coding Specialist II (Remote)

Stanford Health Care

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, MS-DRG or APR-DRG classifications, and required abstracted data. The role handles the majority of inpatient patient types, including complex cases such as Intensive Care, and follows official coding guidelines, AHIMA ethical coding standards, AHA Coding Clinic guidance, and Stanford Health Care policies and procedures. The position ensures coding, billing, data collection, and reimbursement compliance with federal, state, and third-party requirements while meeting established quality and productivity standards. The specialist verifies discharge disposition and admission source, assigns present-on-admission indicators, and ensures codes support the provider-documented reason for the visit and care provided. The role monitors Discharged Not Billed accounts, collaborates with Clinical Documentation Specialists and medical staff to support complete documentation, and uses coding and abstracting software to validate information. It requires independent work, sound judgment, effective communication, and ongoing attention to current CMS requirements and related coding rules. The position is remote and has a day schedule of eight hours.

Requirements

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

Responsibilities

Review inpatient medical record documentation and assign accurate ICD-10 diagnosis and procedure codes, resulting in the appropriate MS-DRG or APR-DRG.
Verify patient discharge disposition and assign the correct source of admission for state reporting.
Assign appropriate present-on-admission indicators and ensure codes support the provider-documented reason for the visit and care provided.
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 support complete medical record documentation and appropriate code and DRG assignment.
Maintain established accuracy, quality, and productivity standards.
Stay current on CMS requirements, CCI edits, HACs, PSIs, applicable NCDs and LCDs, and appropriate modifiers to support clean claims.
Use coding, audit, documentation improvement, and abstracting tools and reference materials to maintain competency and accuracy.
Follow Stanford Health Care policies and procedures.
Attend required system, hospital, and departmental meetings and educational sessions, and complete required annual learning programs.