Certified Medical Records Coder-Inpatient (Riverside)

About The Position

The County of Riverside - Riverside University Health System - Medical Records Department is seeking to fill a Certified Medical Records Coder position located in Riverside. Under general supervision, performs advanced coding and abstracting of inpatient medical record entries according to the most current edition of International Classification of Diseases - Clinical Modification System (ICD-CM), Procedure Coding System (PCS) and Current Procedural Terminology (CPT); performs other related duties as required.

Responsibilities

• Code medical record entries pertaining to diagnoses and procedures according to the most current edition of ICD-CM, and when applicable PCS and CPT;
• Enter information into the designated computer system;
• Abstract patient information such as Admission, Discharge and Transfer (ADT), type of surgery, type of anesthesia, length of stay, and assist clinical providers as needed;
• Query physicians when assistance is needed for proper identification of codes for diagnoses or procedures; communicate with physicians and others involved in the treatment of patients as needed;
• Work with Clinical Documentation Improvement Team when there are conflicting diagnoses, ambiguous, inconsistent, missing, and unclear clinical documentation by the physician to support code assignment;
• Assist and provide coding training to Certified Medical Record Coder - Outpatient as needed.

Requirements

• Four years as a Certified Medical Records Coder - Outpatient with the County of Riverside.
• Two years of inpatient medical record coding experience in an acute care setting using ICD-CM, PCS and CPT coding. (Experience must have been within the last four years.)
• Knowledge of: ICD-CM, PCS and CPT classification coding systems and DRG assignment; the fundamentals of anatomy, physiology and the study of diseases; standard clerical office procedures and equipment, including Windows-based software use.
• Ability to: Utilize the ICD-CM classification system to code medical record entries either by use of coding books or encoder product; abstract pertinent information from medical records; follow oral and written instructions; operate PC with Windows software, coding software and abstract package; effectively communicate technical information to medical and administrative personnel; maintain effective working relationships with others.

Qualifications

• Possession of current valid certification as a Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Administrator (RHIA) or a Registered Health Information Technician (RHIT) issued by American Health Information Management Association, or Certified Professional Coder-Hospital (CPC-H) issued by the American Academy of Professional Coders.

Benefits

Not specified.

Schedule

This position offers a hybrid work schedule, which may include working both in the office and remotely, at the department’s discretion. The selected candidate must maintain both the productivity and accuracy standards established by the department. Employees may be required to work swing shifts, weekends, and some holidays depending on operational needs.

Pay

Not specified.