Health Information Coder 3

About the role

The Health Information Coder III is a senior level inpatient coder with an advanced knowledge and skill set to utilize the ICD-10-CM, ICD-10-PCS, CPT, HCPCS classification systems.

Responsibilities

• Coding and abstracting cases to comply with official guidelines for coding and reporting, practice standards, and code of ethics for HIMS coder.
• Abstracting cases according to UCSF Health policies and procedures.
• Translating detailed clinical documentation into standardized alphanumeric codes for accurate communication, billing, compliance, and data use across hospitals, clinics, insurers, and public health agencies.

Requirements

• High school diploma or equivalent.
• CCS, CIC, RHIT, or RHIA certification.
• Three (3) or more years of experience in inpatient DRG coding and abstracting.
• Successfully pass the initial knowledge assessment with a score of 80% or higher, or have at least six (6) months of recent inpatient DRG coding experience with UCSF and demonstrate an 80% accuracy rate.
• Able to meet or exceed daily production requirements while maintaining a minimum 95% accuracy rate.
• Advanced proficiency with electronic health record (EHR) and encoder systems.
• Advanced computer skills, including proficiency with Windows, Microsoft Word, and Microsoft Excel.
• Excellent written and verbal communication skills and demonstrated ability to work collaboratively with others.
• Strong analytical, problem-solving, and decision-making skills, with the ability to exercise independent judgment.
• Able to understand and follow written instructions and established procedures.
• Strong organizational skills with the ability to prioritize work and manage time effectively.
• Able to meet deadlines and perform effectively in a fast-paced environment and under pressure.
• Advanced knowledge of medical terminology, medical abbreviations, disease processes, anatomy, and physiology.
• Advanced knowledge of ICD-10-CM, ICD-10-PCS, and CPT classification systems.
• Knowledge of current inpatient DRG coding guidelines, methodologies, and applicable regulatory requirements.

Qualifications

• CCS, CIC, RHIT, or RHIA certification.
• Preferred: Knowledge of HIMS database systems. Knowledge of HIMS procedures.