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HEALTH INFORMATION MANAGEMENT CODER I / CODER II

Job Field: Hospitality Jobs
Location: Santa Rosa, CA
Salary: $Not stated
JOB SUMMARY:
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<tr><td valign="top" width="450"><b>Title: Health Information Management Coder I / Coder IILocation: Santa Rosa, CACoders II differ from Coders I in the type & amountt of supervision received; responsibility for data comprehensiveness & quality assurance; data analysis, knowledge of procedures related to the sequencing of diagnoses & interventions, data mgmt policies & procedures; req''d quantity & quality perf standards.Essential Functions:- Reviews medical records to identify diagnoses/procedures- Selects the DRG for each inpatient case- Reviews DRG discrepancies from the fiscal intermediary to ensure appropriate DRG assignment/case- Verifies all medical data from the record to complete a data abstract on each hosp encounter- Ensures that all data abstracted/coded are consistent w/ guidelines outlined by The Joint Commission, OSHPD, CMS, regional/local policy- Enters patient info into computerized med record databases; ensures accuracy & integrity of the medical record abstract/encounter data prior to transmitting case to Government Reimbursement- Ensures timely record availability by meeting est. coding & abstracting productivity/quality standards- Maintains & complies w/ policies & procedures for confidentiality of all patient records- Other duties as assigned- HIM CODER I - ADDITIONAL ESSENTIAL DUTIES: Under gen supervision, organizes/prioritizes all work to ensure records are coded in timeframes that comply w/ regulations- Knowledge of all procedures concerning sequencing of diagnoses, procedures in but not limited to ICD-9-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines & other approp. classification systems- Interacts w/ physicians to clarify/accurately document patient diagnostic & procedural info- Knowledge of anatomy/physiology to interpret medical classifications for coding outpatient encounter/inpatient discharge data- Under dir supervision, codes all diagnostic & operative info from medical record using ICD-9-CM, CPT, HCPCS level 2 coding classif. systems- Participates in med record documentation auditing to monitor physician compliance w/ regulations- Acts as a resource to hospital depts on coding questions/issues- HIM CODER II - ADDITIONAL ESSENTIAL DUTIES: Organizes/prioritizes work to ensure records are coded in timeframes that comply w/ regulations- Expert-level knowledge of all procedures concerning sequencing of diagnoses/procedures including those outlined in ICD-9-CM, CPT, Uniform Hosp Discharge Data Set, Medicare guidelines & other approp classification systems- Knowledge of anatomy/physiology to interpret general med classifications for discharge data including the most complicated encounters/cases- Codes all diagnostic & operative info from medical record using ICD-9-CM, CPT & HCPCS coding classif systems. Quality checks own work- Optimizes hosp payment legitimately & ethically by using approved coding guidelines & conventions- Interacts w/ physicians to clarify & accurately document patient diagnostic & procedural info- Independently conducts med record documentation auditing to monitor physician compliance w/ regulations- Acts as expert resource to coders & other hosp depts on coding questions/issues- This position has no supervisory responsibilities. Coder II''s may provide guidance & assistance to codersThe above duty statements are intended to describe the general nature & level of work being performed by individuals assigned to positions in this classification, they are not intended to be construed as an exhaustive list of duties, responsibilities & skills required of every position so classifiedQualifications:Basic Qualifications:HIM CODER I- Requires 2+ yrs of continuous hospital experience in coding/abstracting within the last 5 yrs- Requires Certified Coding Associate (CCA) & eligibility to become a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA)- Demonstrated ability to understand the clinical content of a health record

KEY REQUIREMENTS:
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