Coder/Abstractor Clerk I

Salinas Valley HealthSalinas, CA
Onsite

About The Position

Performs ICD-10 HCPCS coding, data abstracting and computer data entry on all inpatient and outpatient medical records. Performs other duties as assigned. Demonstrates competency with accurate and compliant coding utilizing ICD-10 and HCPCS classification using established governing guidelines for complete reporting of conditions and services rendered. Thoroughly reviews chart to ascertain all appropriate diagnosis/procedures, if there is a question regarding the diagnoses/code, refers chart to Coding Compliance Manager. Queries providers for clarification of non-specific diagnoses/procedures. Utilizes computerized coding/abstracting applications. Codes all diagnoses/procedures in accordance to ICD-10 and HCPCS coding principals and established coding guidelines. Assists physicians in proper record completion, including sequencing for appropriate reimbursement. Performs computer data analysis, identifies of potential Patient Safety Indicators, and hospital focused process improvement initiatives. Attends workshops, seminars and in services to maintain current knowledge and certifications. Stays current on published guidelines such as Coding Clinics for on-going compliant coding. Works with the Clinical Documentation Specialists to ensure the highest level of specificity and accuracy is documented in the medical record. Maintains code assignments to meet hospital timely billing standards. Performs other duties as assigned.

Requirements

  • A minimum of a high school diploma or GED required.
  • Coder I & II – CCA/CCPS required. New hires/transfers must be eligible for AHIMA CCA/CCPS certification within one (1) year from date of hire/transfer.
  • Must prove understanding of medical terminology via a pre-employment test.
  • Basic ICD-10/HCPCS knowledge, codes outpatient/ER primarily with some exposure to outpatient clinical, surgical and observation encounters.

Nice To Haves

  • Coder III – CCS required. New hires/transfers must be eligible for AHIMA CCS certification within one (1) year from date of hire/transfer.
  • Coder III – Certified – CCS required.
  • Demonstrates competency in intermediate ICD-10/HCPCS code assignment.
  • At least 6 months coding experience in an acute care hospital.
  • A minimum of at least 2 years inpatient coding experience in an acute care hospital with DRG/APC assignment experience.

Responsibilities

  • Performs ICD-10 HCPCS coding, data abstracting and computer data entry on all inpatient and outpatient medical records.
  • Demonstrates competency with accurate and compliant coding utilizing ICD-10 and HCPCS classification using established governing guidelines for complete reporting of conditions and services rendered.
  • Thoroughly reviews chart to ascertain all appropriate diagnosis/procedures, if there is a question regarding the diagnoses/code, refers chart to Coding Compliance Manager.
  • Queries providers for clarification of non-specific diagnoses/procedures.
  • Utilizes computerized coding/abstracting applications.
  • Codes all diagnoses/procedures in accordance to ICD-10 and HCPCS coding principals and established coding guidelines.
  • Assists physicians in proper record completion, including sequencing for appropriate reimbursement.
  • Performs computer data analysis, identifies of potential Patient Safety Indicators, and hospital focused process improvement initiatives.
  • Attends workshops, seminars and in services to maintain current knowledge and certifications.
  • Stays current on published guidelines such as Coding Clinics for on-going compliant coding.
  • Works with the Clinical Documentation Specialists to ensure the highest level of specificity and accuracy is documented in the medical record.
  • Maintains code assignments to meet hospital timely billing standards.
  • Performs other duties as assigned.
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