County of Santa Clara
Coder II - Trauma Administrative Services Department
County of Santa Clara, California, Missouri, United States, 65018
Coder II – Trauma Administrative Services Department
County of Santa Clara
Description Coder II incumbents work under general supervision, performing moderately complex coding and abstracting of assigned tasks, including, but not limited to, outpatient, inpatient, and specialized medical service records. For training purposes, Coder II incumbents may be assigned moderately complex inpatient records. All coding work must be performed in accordance with applicable Federal and State coding guidelines and the coding policies and procedures of the Santa Clara Valley Health and Hospital System (SCVHHS).
Preferred Candidate The preferred candidate will possess knowledge of trauma data management principles and methods, including experience with trauma registry practices and data analysis in a trauma center setting. The incumbent must hold and maintain a current, applicable coding certification. The position requires possession of a Certified Abbreviated Injury Scale Specialist (CAISS) certification. This certification will be in lieu of the following certifications: Certified Coding Associate (CCA), Certified Medical Coder (CMC-PMI), Certified Medical Coder (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Professional Coder (CPC-AAPC).
Position Details
Position: One (1); FTE 1.0
Shift: Varies
Contact For more information, please contact Dennis Lee at (408) 793-1887 or email dennis.lee@hhs.sccgov.org.
Typical Tasks
Reviews, abstracts, and codes medical-record data using coding systems such as ICD-9-CM, CPT-4, and HCPCS or subsequent adaptations;
May perform coding review or audit of provider charges submitted electronically, charge ticket, or electronic file;
Provides CPT and ICD-9 codes to unit and other staff when required;
Records the coding information into the appropriate charge system such as a computer system, paper-charge ticket, and/or electronic file;
Reviews and abstracts procedural, diagnostic services, and/or facility level of services from the medical record and assigns the appropriate coding;
Identifies and assigns diagnosis, CPT procedural codes, HCPC codes or facility level of service utilizing the current adaptation of the International Classification of Diseases (ICD-9-4), CPT-4, HCPC or LOS;
May assign unique coding required by MediCal or other third-party payers when different than the industry standard by CMS;
Applies knowledge of anatomy, physiology, disease processes, and medical terminology to accurately assign and sequence the procedural coding, diagnoses, or HCPC codes;
Accurately assigns Medicare Severity Diagnosis Related Group (MSDRG) and Ambulatory Payment Classification (APC) number or other coding classifications;
(In Diagnostic Imaging Unit) Reviews various radiology reports for appropriate CPT codes and assigns codes accordingly using ICD-9 code set or subsequent adaptation (such as ICD-10) and performs other coding-related duties pertaining to diagnostic imaging;
Participates in the development of policies and procedures; supports the implementation of departmental policies and procedures;
Reviews Coder I work for completeness and correctness, and assists in the orientation of new staff to the unit;
Reviews and resolves charge errors and/or coding discrepancies;
Follows department policy regarding notification of incomplete or missing information from the patient record;
Communicates with other departments and providers regarding account clarification and corrections;
Maintains HIPAA confidentiality, privacy, and security of all patient-related information;
Maintains harmonious work relationships;
May be assigned as a Disaster Service Worker, as required;
Performs other related work as required.
Qualifications Sufficient education, training, and experience to demonstrate the ability to perform the above tasks, and possession of the following qualifications, including the knowledge and abilities indicated below:
High school diploma (or GED equivalent), possession of a CCA, CMC (PMI), or CCS or RHIT or RHIA or CPC (AAPC) certification, and two (2) years experience as a medical coder which included coding outpatient and/or inpatient records using ICD-9 diagnosis (or subsequent ICD adaptation), procedures CPT codes, HCPS coding system;
Specific certifications such as Radiology Certified Coder (RCC) may be required if specific job duties are such that a particular coding credential is more applicable. Because specific Coder functions and certifications may vary, certifications will be evaluated on a case‑by‑case basis to assess applicability to the Coder II duties assigned as well as the required knowledge and abilities.
Maintain coding competency regarding procedural, diagnosis, HCPC codes and LOS facility charges, a strong understanding of coding, compliance and regulatory payer guidelines, and other guidelines related to coding of medical records.
Complete required Continuing Education Units (CEUs) annually to ensure respective certifications remain active and in good standing.
Knowledge Of
Coding guidelines, abstracting, and medical terminology to utilize and assign appropriate coding: current ICD-9-CM and CPT-4, HCPCs or subsequent adaptations;
Computer encoding software programs, online tools, coding references and websites;
The principles and practice of accurate and compliant abstracting and coding techniques;
Comprehensive medical terminology, anatomy and physiology, and disease processes related to medical specialties;
Components and format of the hard copy and/or electronic version of medical record, including but not limited to laboratory findings, special tests, medications, surgical procedures, therapy services, surgical events, other dictated or handwritten process notes and reports, consents, etc;
English grammar, punctuation, spelling, and general English usage;
Computerized patient data systems.
Ability to
Read and comprehend the elements of a medical chart, medical-record notes, and reports;
Analyze, code, and abstract moderately‑complex technical data from medical records covering a wide variety of ancillary/outpatient—and in some cases inpatient—services;
Identify missing elements, inferred between procedural and treatment relationships;
Properly sequence abstracted/coding information from a medical record;
Read and understand medical record notes and reports and accurately classify all diagnoses and procedures;
Effectively use the various computer systems necessary to perform job functions;
Communicates clearly, both orally and in writing, with medical and nursing staff, employees at all levels of the organization, patients, and the public;
Plan, organize, and prioritize work, and meet deadlines;
Reason logically, and use sound judgment in the performance of duties.
Seniority Level Associate
Employment Type Full-time
Job Function Engineering and Information Technology
Industry: Government Administration
About Santa Clara Valley Healthcare Santa Clara Valley Healthcare (SCVH) is the second-largest public healthcare system in California, comprising three acute‑care hospitals, 14 clinics, and more than 60 specialty and subspecialty services. Our mission is to deliver high‑quality, accessible healthcare and exceptional service to all residents of Santa Clara County.
Hospitals Santa Clara Valley Medical Center (SCVMC) is a full‑service tertiary acute‑care teaching hospital with 699 licensed beds, providing a wide range of specialized services, including Rehabilitation, Burn, Trauma, and NICU. SCVMC was ranked by U.S. News and World Report as the #6 Rehabilitation Hospital in the nation and #1 in the West, and was designated as a 2024 High‑Performing hospital for Maternity Care, Heart Failure, Stroke, Hip Fracture, and Pneumonia.
O'Connor Hospital (OCH) is a 358‑licensed bed acute‑care facility offering a full range of inpatient and outpatient medical, surgical, and specialty programs.
Regional Medical Center (RMC) is a 258‑bed hospital serving as the primary emergency healthcare provider for East San Jose, treating a wide range of critical and life‑threatening conditions. Since the SCVH integration of RMC, effective April 1, 2025, RMC has expanded its critical services, including Level II trauma care, a thrombectomy‑capable stroke center, and STEM care.
St. Louise Regional Hospital (SLRH) has 93 beds, is a Designated Primary Stroke Center, and is the only acute‑care hospital in the area. It maintains a CALSTAR 2 emergency helicopter base on the premises.
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Description Coder II incumbents work under general supervision, performing moderately complex coding and abstracting of assigned tasks, including, but not limited to, outpatient, inpatient, and specialized medical service records. For training purposes, Coder II incumbents may be assigned moderately complex inpatient records. All coding work must be performed in accordance with applicable Federal and State coding guidelines and the coding policies and procedures of the Santa Clara Valley Health and Hospital System (SCVHHS).
Preferred Candidate The preferred candidate will possess knowledge of trauma data management principles and methods, including experience with trauma registry practices and data analysis in a trauma center setting. The incumbent must hold and maintain a current, applicable coding certification. The position requires possession of a Certified Abbreviated Injury Scale Specialist (CAISS) certification. This certification will be in lieu of the following certifications: Certified Coding Associate (CCA), Certified Medical Coder (CMC-PMI), Certified Medical Coder (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Professional Coder (CPC-AAPC).
Position Details
Position: One (1); FTE 1.0
Shift: Varies
Contact For more information, please contact Dennis Lee at (408) 793-1887 or email dennis.lee@hhs.sccgov.org.
Typical Tasks
Reviews, abstracts, and codes medical-record data using coding systems such as ICD-9-CM, CPT-4, and HCPCS or subsequent adaptations;
May perform coding review or audit of provider charges submitted electronically, charge ticket, or electronic file;
Provides CPT and ICD-9 codes to unit and other staff when required;
Records the coding information into the appropriate charge system such as a computer system, paper-charge ticket, and/or electronic file;
Reviews and abstracts procedural, diagnostic services, and/or facility level of services from the medical record and assigns the appropriate coding;
Identifies and assigns diagnosis, CPT procedural codes, HCPC codes or facility level of service utilizing the current adaptation of the International Classification of Diseases (ICD-9-4), CPT-4, HCPC or LOS;
May assign unique coding required by MediCal or other third-party payers when different than the industry standard by CMS;
Applies knowledge of anatomy, physiology, disease processes, and medical terminology to accurately assign and sequence the procedural coding, diagnoses, or HCPC codes;
Accurately assigns Medicare Severity Diagnosis Related Group (MSDRG) and Ambulatory Payment Classification (APC) number or other coding classifications;
(In Diagnostic Imaging Unit) Reviews various radiology reports for appropriate CPT codes and assigns codes accordingly using ICD-9 code set or subsequent adaptation (such as ICD-10) and performs other coding-related duties pertaining to diagnostic imaging;
Participates in the development of policies and procedures; supports the implementation of departmental policies and procedures;
Reviews Coder I work for completeness and correctness, and assists in the orientation of new staff to the unit;
Reviews and resolves charge errors and/or coding discrepancies;
Follows department policy regarding notification of incomplete or missing information from the patient record;
Communicates with other departments and providers regarding account clarification and corrections;
Maintains HIPAA confidentiality, privacy, and security of all patient-related information;
Maintains harmonious work relationships;
May be assigned as a Disaster Service Worker, as required;
Performs other related work as required.
Qualifications Sufficient education, training, and experience to demonstrate the ability to perform the above tasks, and possession of the following qualifications, including the knowledge and abilities indicated below:
High school diploma (or GED equivalent), possession of a CCA, CMC (PMI), or CCS or RHIT or RHIA or CPC (AAPC) certification, and two (2) years experience as a medical coder which included coding outpatient and/or inpatient records using ICD-9 diagnosis (or subsequent ICD adaptation), procedures CPT codes, HCPS coding system;
Specific certifications such as Radiology Certified Coder (RCC) may be required if specific job duties are such that a particular coding credential is more applicable. Because specific Coder functions and certifications may vary, certifications will be evaluated on a case‑by‑case basis to assess applicability to the Coder II duties assigned as well as the required knowledge and abilities.
Maintain coding competency regarding procedural, diagnosis, HCPC codes and LOS facility charges, a strong understanding of coding, compliance and regulatory payer guidelines, and other guidelines related to coding of medical records.
Complete required Continuing Education Units (CEUs) annually to ensure respective certifications remain active and in good standing.
Knowledge Of
Coding guidelines, abstracting, and medical terminology to utilize and assign appropriate coding: current ICD-9-CM and CPT-4, HCPCs or subsequent adaptations;
Computer encoding software programs, online tools, coding references and websites;
The principles and practice of accurate and compliant abstracting and coding techniques;
Comprehensive medical terminology, anatomy and physiology, and disease processes related to medical specialties;
Components and format of the hard copy and/or electronic version of medical record, including but not limited to laboratory findings, special tests, medications, surgical procedures, therapy services, surgical events, other dictated or handwritten process notes and reports, consents, etc;
English grammar, punctuation, spelling, and general English usage;
Computerized patient data systems.
Ability to
Read and comprehend the elements of a medical chart, medical-record notes, and reports;
Analyze, code, and abstract moderately‑complex technical data from medical records covering a wide variety of ancillary/outpatient—and in some cases inpatient—services;
Identify missing elements, inferred between procedural and treatment relationships;
Properly sequence abstracted/coding information from a medical record;
Read and understand medical record notes and reports and accurately classify all diagnoses and procedures;
Effectively use the various computer systems necessary to perform job functions;
Communicates clearly, both orally and in writing, with medical and nursing staff, employees at all levels of the organization, patients, and the public;
Plan, organize, and prioritize work, and meet deadlines;
Reason logically, and use sound judgment in the performance of duties.
Seniority Level Associate
Employment Type Full-time
Job Function Engineering and Information Technology
Industry: Government Administration
About Santa Clara Valley Healthcare Santa Clara Valley Healthcare (SCVH) is the second-largest public healthcare system in California, comprising three acute‑care hospitals, 14 clinics, and more than 60 specialty and subspecialty services. Our mission is to deliver high‑quality, accessible healthcare and exceptional service to all residents of Santa Clara County.
Hospitals Santa Clara Valley Medical Center (SCVMC) is a full‑service tertiary acute‑care teaching hospital with 699 licensed beds, providing a wide range of specialized services, including Rehabilitation, Burn, Trauma, and NICU. SCVMC was ranked by U.S. News and World Report as the #6 Rehabilitation Hospital in the nation and #1 in the West, and was designated as a 2024 High‑Performing hospital for Maternity Care, Heart Failure, Stroke, Hip Fracture, and Pneumonia.
O'Connor Hospital (OCH) is a 358‑licensed bed acute‑care facility offering a full range of inpatient and outpatient medical, surgical, and specialty programs.
Regional Medical Center (RMC) is a 258‑bed hospital serving as the primary emergency healthcare provider for East San Jose, treating a wide range of critical and life‑threatening conditions. Since the SCVH integration of RMC, effective April 1, 2025, RMC has expanded its critical services, including Level II trauma care, a thrombectomy‑capable stroke center, and STEM care.
St. Louise Regional Hospital (SLRH) has 93 beds, is a Designated Primary Stroke Center, and is the only acute‑care hospital in the area. It maintains a CALSTAR 2 emergency helicopter base on the premises.
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