HIM Coder I / Coder II Job in Santa Clara, California Us

Coders II differ from Coders I in the type amountt of supervision received; responsibility for data comprehensiveness quality assurance; data analysis, knowledge of procedures related to the sequencing of diagnoses interventions, data mgmt policies procedures; req'd quantity quality perf standards.
Essential Functions:
- Reviews medical records to identify diagnoses/procedures
- Selects the DRG for each inpatient case
- Reviews DRG discrepancies from the fiscal intermediary to ensure appropriate DRG assignment/case
- Verifies all medical data from the record to complete a data abstract on each hosp encounter
- Ensures that all data abstracted/coded are consistent w/ guidelines outlined by The Joint Commission, OSHPD, CMS, regional/local policy
- Enters patient info into computerized med record databases; ensures accuracy integrity of the medical record abstract/encounter data prior to transmitting case to Government Reimbursement
- Ensures timely record availability by meeting est. coding abstracting productivity/quality standards
- Maintains complies w/ policies procedures for confidentiality of all patient records
- Other duties as assigned
- HIM CODER I - ADDITIONAL ESSENTIAL DUTIES: Under gen supervision, organizes/prioritizes all work to ensure records are coded in timeframes that comply w/ regulations
- Knowledge of all procedures concerning sequencing of diagnoses, procedures in but not limited to ICD-9-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines other approp. classification systems
- Interacts w/ physicians to clarify/accurately document patient diagnostic procedural info
- Knowledge of anatomy/physiology to interpret medical classifications for coding outpatient encounter/inpatient discharge data
- Under dir supervision, codes all diagnostic operative info from medical record using ICD-9-CM, CPT, HCPCS level 2 coding classif. systems
- Participates in med record documentation auditing to monitor physician compliance w/ regulations
- Acts as a resource to hospital depts on coding questions/issues
- HIM CODER II - ADDITIONAL ESSENTIAL DUTIES: Organizes/prioritizes work to ensure records are coded in timeframes that comply w/ regulations
- Expert-level knowledge of all procedures concerning sequencing of diagnoses/procedures including those outlined in ICD-9-CM, CPT, Uniform Hosp Discharge Data Set, Medicare guidelines other approp classification systems
- Knowledge of anatomy/physiology to interpret general med classifications for discharge data including the most complicated encounters/cases
- Codes all diagnostic operative info from medical record using ICD-9-CM, CPT HCPCS coding classif systems. Quality checks own work
- Optimizes hosp payment legitimately ethically by using approved coding guidelines conventions
- Interacts w/ physicians to clarify accurately document patient diagnostic procedural info
- Independently conducts med record documentation auditing to monitor physician compliance w/ regulations
- Acts as expert resource to coders other hosp depts on coding questions/issues
- This position has no supervisory responsibilities. Coder II's may provide guidance assistance to coders
The above duty statements are intended to describe the general nature level of work being performed by individuals assigned to positions in this classification, they are not intended to be construed as an exhaustive list of duties, responsibilities skills required of every position so classified

Qualifications:
Basic Qualifications:
HIM CODER I
- Requires 2+ yrs of continuous hospital experience in coding/abstracting within the last 5 yrs
- Requires Certified Coding Associate (CCA) eligibility to become a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA)
- Demonstrated ability to understand the clinical content of a health record
HIM CODER II
- Requires 3+ yrs of hospital inpatient experience coding within the last 5 yrs
- Requires certification as a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) - Demonstrated ability to understand the clinical content of a health record, including the most complicated records
- Ability to demonstrate knowledge of utilize auditing skills related to coding quality compliance
- Background knowledge of analysis, assembly, terminal digit filing, physician's incomplete processing preferred
HIM CODER I/II - ADDITIONAL QUALIFICATIONS:
- High School Diploma/GED
- Completion of classes in medical terminology, anatomy, physiology, ICD-9 CPT coding conventions, disease process from an accredited program
- Must be able to communicate w/ physicians to clarify diagnoses, procedures, sequencing of diagnoses
- Basic PC skills
- Requires 75% on the Kaiser coding test
- Must be able to meet established quantity quality standards
- Must maintain current coding credential a minimum of 10 CEUs annually
- Must abide by the AHIMA coding code of ethics
- Must be willing to work in a Labor Management Partnership environment
- Additional qualifications may be outlined in the appropriate collective bargaining agreement

Skills Testing: Basic PC skills. Requires 75% on the Kaiser coding test