Hospital Outpatient Coder

About the role

Under direct supervision, the Hospital Outpatient Coder is responsible for the accurate coding and abstracting of diagnoses, conditions and procedures from medical record documentation for Hospital Ambulatory Surgery (HAS), Home Health/Hospice (if applicable), Observation (OBS) and Hospital complex Outpatient Visit (CHOY) including capture of codes for outpatient services that require monitored anesthesia and conscious sedation.

Key responsibilities

• Review medical records to identify diagnoses/procedures to be coded
• Assign appropriate codes and modifiers with ICD-CM, CPT and HCPCS Level II codes from appropriate documentation
• Independently organize and prioritize work assignments to ensure records are coded timely and compliantly in conformance with regulatory requirements
• Code all appropriate diagnosis and procedures from the medical record using ICD-CM, CPT and HCPCS coding classification systems
• Responsible for sequencing of diagnoses and procedure codes in accordance with guidelines outlined in ICD-CM, CPT, Uniform Hospital Discharge Data Set, Medicare regulations and other appropriate classification systems
• Verify and abstract appropriate data from medical records to meet requirements for data submission and reporting; correct data as needed
• Ensure all data abstracted is consistent with guidelines outlined by TJC, OSHPD, CMS, and regional and local KP policies
• Ensure accuracy and integrity of data abstracted and coded based on medical record documentation prior to data submission or coding completion
• Interact with physicians to clarify and accurately document patient diagnostic and procedural information when appropriate
• Ensure timely data completion by meeting coding/abstracting productivity/quality standards established for the position
• Maintain and comply with policies and procedures for confidentiality of all patient records
• Demonstrate knowledge of privacy and security of systems and associated policies and procedures for maintaining the security of the data contained within the systems
• Perform other duties as assigned

Required qualifications

• Two years of continuous hospital coding/abstracting experience within the last five years
• High School Diploma or GED and demonstrated completion of classes in medical terminology, anatomy, physiology, current ICD-CM and CPT coding conventions and disease process from an accredited program
• Registered Health Information Technician OR Certified Professional Coder OR Certified Coding Specialist OR Certified Coding Associate OR Registered Health Information Administrator OR Certified Coding Specialist - Physician Based
• Achieve a minimum score of 75% on the Hospital Outpatient Coder test
• Basic knowledge of and use of computer keyboard and mouse
• Must be able to meet productivity and quality standards established for the position
• Demonstrated ability to understand the clinical content of a health record and translate into the appropriate code
• Demonstrated knowledge of anatomy, physiology, medical terminology and disease process to interpret general medical classifications for Hospital Ambulatory Services, Home Health/Hospice, and Hospital Observation Services and CHOY services that require monitored anesthesia or conscious sedation
• Demonstrated knowledge pertaining to all guidelines that concern the coding and sequencing of diagnoses and procedures outlined in but not limited to current ICD-CM, CPT, Medicare guidelines and other sources
• Basic knowledge of reimbursement methodologies and conventions and knowledge of rules and guidelines for the appropriate and current coding classifications
• Must maintain coding credential and complete the required Continuing Education (CE) units
• Must abide by the AHIMA and/or AAPC code of ethics
• Must be willing to work in a Labor Management Partnership environment
• Must reside in Northern California

Work schedule

• Shift: Day
• Workdays: Mon, Tue, Wed, Thu, Fri
• Working Hours: 07:00 AM – 03:30 PM
• Full-time

Pay

$51.85 – $56.91 / hour