Coder III - Inpatient - Extra Help
Full Time
San Jose, CA
Posted
Job description
Description
Under direction, to perform the most complex medical-record coding and abstracting duties of the Coder series, requiring advanced medical-record coding knowledge and skills. Coder III-Inpatient incumbents primarily work with moderate to highly-complex inpatient records, but may also perform coding and abstracting of outpatient records.
This recruitment is for EXTRA-HELP (Temporary) assignments only. T he Extra Help opportunities will be on-site, located at the Silver Creek Office.
COVID-19 Risk Tier – Lower Risk
Learn more about Santa Clara Health System at:
scvmc.org, och.sccgov.org, slrh.sccgov.org
Twitter I @scvmctalent
Facebook I facebook.com/SCVMC
LinkedIn | linkedin.com/scvmc
scvmc.org, och.sccgov.org, slrh.sccgov.org
Twitter I @scvmctalent
Facebook I facebook.com/SCVMC
LinkedIn | linkedin.com/scvmc
Typical Tasks
- Reviews and analyzes a wide variety of primarily inpatient medical record information, such as diagnostic, operative, monitoring, and life-sustaining medical procedures for coding and abstracting purposes;
- Codes a wide variety of inpatient procedures and primary and secondary diagnoses according to the International Classification of Diseases (i.e., ICD-9-CM or subsequent adaptation, such as ICD-10-CM/ PCS), Current Procedural Terminology (CPT-4), and other coding systems applicable to Medi-Cal, Medicare, and other patient insurances;
- Assigns Medicare Severity Diagnostic Related Group (MSDRG) and Ambulatory Payment Classification (APC) numbers;
- Relies on a knowledge of anatomy, physiology, disease processes, and medical terminology in order to complete and properly sequence the coding of procedures and diagnoses, and to determine proper codes for diagnoses and procedures not clearly listed in the ICD and CPT codes;
- Organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements and hospital targets;
- Abstracts and prepares pertinent medical chart data-for statistical indexing, studies, approved Institutional Research Boards (IRB's) and preparation of summary reports to various agencies-in accordance with criteria established by the facility and/or the Office of Statewide Hospital Planning and Development (OSHPD) and/or including (but not limited to) other Federal and State regulatory bodies, and individual physicians;
- Enters appropriate patient information into the computerized inpatient and/or outpatient medical record databases;
- Proofreads computer input and output to ensure the correctness of entries and reviews rejected entries to identify and correct errors;
- Communicates in writing with (i.e. queries) medical staff regarding incomplete or missing medical record information;
- Acts as an expert resource person and may provide guidance and assistance to other coders;
- Maintains harmonious work relationships;
- May be assigned as a Disaster Service Worker, as required;
- Performs other related work as required.
Employment Standards
Sufficient education, training, and experience to demonstrate the ability to perform the above tasks, and possession of the following qualifications, including the knowledge and abilities indicated below:
Training and Experience Note:
The knowledge and abilities required to perform this function are typically acquired through training and experience equivalent to graduation from a high school (or GED equivalent), certification by the American Health Information Management Association as a Certified Coding Specialist (CCS) plus one or more years of acute care hospital outpatient and inpatient hospital coding/abstracting experience within the last five (5) years. Work experience must have involved utilizing an encoder program for Medicare reimbursement coding, ICD-9 diagnosis and procedure coding, CPT coding, MS-DRG, and APR-DRG assignment.
Demonstrated competency in coding and abstracting medical records, in accordance with ICD-9-CM (or subsequent adaptation) and CPT-4 systems, or other applicable medical coding systems as required.
Knowledge of:
- Coder-related regulatory and data reporting agencies and their functions;
- Coding , abstracting, and terminology systems such as: International Classifications and Diseases 9-Clinically Modified (ICD 9-CM or subsequent adaptation) coding system; current CPT- 4 procedural coding system, Medial Severity Diagnosis Related Group (MSDRG) system, and abstracting systems;
- The abstract patient data fields, abstracting and coding techniques and statistical methods, and OSHPD reporting requirements;
- Comprehensive medical terminology covering a wide variety of medical specialties, including anatomy and physiology and the disease process;
- Components and format of the medical record, including but not limited to laboratory findings, special tests, medications, surgical procedures, therapy systems, surgery and other reports, history and progress notes, and consent documentation;
- The organization, services, and patient treatment interrelationships and sequences of a comprehensive teaching hospital;
- Health Information Management Services procedures;
- The complete revenue management cycle;
- English grammar, punctuation, and spelling and general English usage;
- Computerized patient data systems;
- Basic mathematics.
Ability to:
- Collect and analyze inpatient clinical information in order to accurately report codes and abstract relevant information used for processing reimbursement claims, research, statistical analysis, and other purposes such as clinical care improvement, financial planning, and marketing initiatives;
- Effectively use various computer systems in the performance of job functions;
- Read and comprehend the technical elements of a medical chart;
- Analyze, code, and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system;
- Consistently code complex patient medical records at established productivity rates and with an accuracy rate of 95% or above;
- Recognize missing elements, infer procedural and treatment relationships, and properly sequence information for coding and abstracting data from a medical record;
- Prepare clear and concise narrative, statistical, and graphic reports;
- Set work priorities and work independently, exercising considerable independent judgment;
- Communicate clearly both verbally and in writing with the public, patients, medical, nursing, technical staff, and legal counsel;
- Work effectively and harmoniously with others;
- Code and abstract inpatient records in accordance with agency-approved coding systems and national coding guidelines;
- Maintain an understanding of regulations, standards and practices as they relate to Health Information Management;
- Safely perform physical activities such as: reaching over ones head and bending down to retrieve files, standing, pulling records, and/or sitting for long periods of time, periodic lifting moderately heavy file containers (up to 50 pounds) and pushing heavy carts (may be required for some positions).
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