Santa Clara County
Coder II - Trauma Administrative Services Department
Santa Clara County, San Jose, California, United States, 95199
Coder II – Trauma Administrative Services Department
Coder II incumbents work under general supervision, performing moderately complex coding and abstracting of assigned tasks, including 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).
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
We are currently recruiting for one (1) full‑time Coder II position within the Trauma Administrative Services Department at the Regional Medical Center. For more information, please contact Dennis Lee at (408) 793‑1887 or email dennis.lee@hhs.sccgov.org.
Key Responsibilities
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 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.
Required Qualifications Certification:
Certified Abbreviated Injury Scale Specialist (CAISS).
Experience:
Sufficient education, training, and experience to demonstrate the ability to perform the above tasks, including possession of a 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, HCPCS coding system. Specific certifications such as Radiology Certified Coder (RCC) may be required if specific job duties require a particular coding credential.
Coders are required to maintain their 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. Coders must complete the required Continuing Education Units (CEUs) annually to ensure their respective certifications remain active and in good standing.
Key Knowledge Areas
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 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.
Key Abilities
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, infer 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.
Communicate 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.
Equality: Santa Clara Valley Healthcare is an Equal Opportunity Employer; all qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other legal protected characteristics.
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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
We are currently recruiting for one (1) full‑time Coder II position within the Trauma Administrative Services Department at the Regional Medical Center. For more information, please contact Dennis Lee at (408) 793‑1887 or email dennis.lee@hhs.sccgov.org.
Key Responsibilities
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 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.
Required Qualifications Certification:
Certified Abbreviated Injury Scale Specialist (CAISS).
Experience:
Sufficient education, training, and experience to demonstrate the ability to perform the above tasks, including possession of a 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, HCPCS coding system. Specific certifications such as Radiology Certified Coder (RCC) may be required if specific job duties require a particular coding credential.
Coders are required to maintain their 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. Coders must complete the required Continuing Education Units (CEUs) annually to ensure their respective certifications remain active and in good standing.
Key Knowledge Areas
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 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.
Key Abilities
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, infer 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.
Communicate 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.
Equality: Santa Clara Valley Healthcare is an Equal Opportunity Employer; all qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other legal protected characteristics.
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