HEALTH INFO CODER 3, Per Diem

The Health Information Coder III, Per Diem is a senior-level inpatient coder with the knowledge and skill set to utilize the ICD-10-CM and ICD-10-PCS classification systems to code acute academic, teaching inpatient cases. The skill set extends to knowledge and comprehension of code sequences into Diagnoses-Related Groups on acute academic, teaching inpatient cases. Cases are coded to comply with the official guidelines for coding and reporting, practice standards and code of ethics for HIMS coder. Cases are abstracted according to UCSF Health policies and procedures. The focus of coding and abstracting is on a range of all primary hospital services. There is minimal review of coding for quality.

DUTIES AND ESSENTIAL JOB FUNCTIONS

Retrieve and analyze comprehensive medical records and information systems for appropriate documentation and follow-up as appropriate. Evaluate full episode of care of clinical data for inpatient cases and assign appropriate codes using ICD-10-CM andICD-10-PCS classification systems. Includes assessment of the condition and diagnosis to conclude the coding of clinical data and DRG assignment. Meet external requirements for HCAI, HCFA, The Joint Commission, NCQA and payor data requirements. Accurately input codes and abstract data into current coding databases. Participate in coding audits and coding educational sessions and provide feedback and training. Meet or exceed department production standards for the DRG coding level. Meet or exceed department quality standards for the DRG coding level. Maintain knowledge of current medical terminology, disease processes, anatomy & physiology, and current DRG coding guidelines. Follow-up and clarify physician documentation (dictation and clinical notes). Report to a lead or manager. Interact with internal and external UCSF Health staff and customers. Satisfactory time and attendance

OTHER FUNCTIONS AND RESPONSIBILITIES

Demonstrate understanding of DRG coding mission within UCSF Health. Demonstrate understanding of DRG coding, AR, and data submission information flow. Ability to solve problems and troubleshoot computer issues. Perform data searches. Maintain patient confidentiality and IT security. Treat others with respect and work well on a team. As requested, train others. Follow safety and infection control guidelines. Maintain equipment and work area Comply with the UCSF Health dress code. Other duties as assigned.