AM Shift 40 Hours/Week

JOB SUMMARY: The Coder II analyzes abstracts and codes the diagnostic and procedural information for inpatient and outpatient medical records utilizing the International Classifications of Diseases, tenth revision (ICD-10), and Current Procedural Terminology (CPT) in accordance with regulatory agencies and hospital-specific guidelines. The Coder II enters the coded data and other abstracted data from the medical record into the electronic information system, facilitating the Health Information Services departments indexing responsibility for internal use (such as to support medical care evaluation studies) and mandated reporting requirements. Holding a senior coding position, assuming primary responsibility for DRG optimization, primary role in assisting medical staff members with improving the quality of documentation, and serving as a mentor to the Coder and Coder I. Participates in chart review projects as assigned.

DUTIES AND RESPONSIBILITIES
-Maintain confidentially, protecting patient information at all times: minimum information necessary to those with right and need to know.
-Conduct a thorough review of the documentation available in the record, and accurately assign the appropriate principle and secondary, diagnosis and procedures.
-Apply the Current Procedural Terminology (CPT) coding convention & general guidelines published by the American Medical Association (AMA) for surgical and diagnostic procedure coding.
-Follow coding guidelines as specified by AHA Coding Clinic and hospital policy. Commit to code assignment and data reporting in an unbiased, honest and ethical manner.
-Abstract patient data correctly and accurately complete all required elements in the electronic information system. Follow department policy and UHDDS abstracting guidelines, facilitating a positive outcome in the OSHPD error reports.
-Ensure all pertinent documentation is available in the record for final coding and abstracting.
-Discrepancies identified upon review of the medical record, for example in the content and quality of the transcribed report, are addressed appropriately.
-Consult with medical staff members when necessary, for purposes of clarification of diagnoses and/or procedures.
-Queries are formulated well; are clear, concise, and affect efficient assistance to the medical staff member for timely and accurate query response, complete documentation, and final coding.
-Perform as a liaison, assisting medical staff members through education and feedback to improve the quality of documentation within the body of the medical record.
-Follow department policy for prioritization of records to be coded, including STAT requests.
-Consistently update coding status in the abstract module. Monitor un-coded records, taking the initiative to resolve any issues and ensure timely abstracting and coding of data.
-Consistently files medical records as assigned and in strict terminal-digit order.
-Accurately maintains and consistently utilizes the chart location system.
-Serve as a role model and provide mentorship, assisting in the professional development of the Coder and Coder I staff members. -Effective communication: writes and speaks clearly and concisely, affecting positive and efficient assistance to all requestors.
-Perform required tasks and other duties as assigned, while maintaining a positive attitude.
-Completes job duties in accordance with production requirements and quality standards.
-Promptly report equipment malfunctions to the appropriate personnel to order service as needed.
-Inventory supplies are needed to perform job duties and place orders on a regular basis to ensure an adequate supply at all times.
-Initiate & participate in required and voluntary continuing education opportunities, enhancing professional growth and maintaining CEUs required for certification and/or by department policy.
-Maintains current AHIMA certification. Submits copy to Director in a timely manner.
-Other duties as assigned or required.

Required Qualification:
1. Minimum one year of experience with ICD-10 and CPT coding in an acute care setting; required.
2. Basic computer experience; required.
3. Use of an encoder software product for code assignment in an acute care setting; preferred.
4. Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm; preferred.
5. Successful completion of college-level courses in anatomy, physiology, medical terminology, and coding ICD and CPT; are required.
6. Successful completion of or current enrollment in a program for certification as a Certified Coding Specialist (C.C.S.), Registered Health Information Technician (R.H.I.T.), or Registered Health Information Administrator (R.H.I.A.); required.
7. Certification or license as a Certified Coding Specialist (C.C.S.), highly desired.

Vaccine requirement

To protect the health of our patients and our health care workers, and to preserve the safety of the St. Rose Hospital healthcare environment, we require all health system employees, trainees, volunteers, and others who regularly work within the health system to be fully vaccinated against COVID-19, including booster.

Location: 27200 Calaroga Avenue,HAYWARD,ALAMEDA,CALIFORNIA,UNITED STATES - 94545, Hayward, CA 94545

Job Type: Full-time

Pay: Up to $33.66 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift

Ability to commute/relocate:

• Hayward, CA 94545: Reliably commute or planning to relocate before starting work (Preferred)

License/Certification:

• CCS, RHIT, or RHIA (Required)

Work Location: In person

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