Health Information Coder 3, Per Diem

DaMar Staffing; United States; On-site; USD 83,000 - 110,000; Full time

Job summary

UCSF Health seeks a Health Information Coder III for per diem inpatient coding using ICD-10-CM and ICD-10-PCS. You will code acute inpatient cases, ensure DRG accuracy, and adhere to coding guidelines in a teaching hospital setting.

You will retrieve records, analyze clinical data, input codes, and participate in audits while maintaining confidentiality and information security. Per diem role with UCSF Health procedures.

Qualifications

• ICD-10-CM and ICD-10-PCS coding knowledge required.
• Familiarity with DRG assignment and coding guidelines.
• Ability to analyze medical records and follow documentation requirements.
• Commitment to patient confidentiality and IT security.

Responsibilities

• Retrieve and analyze comprehensive medical records for documentation and follow-up.
• Evaluate inpatient care, assign codes using ICD-10-CM/PCS and DRG.
• Input codes and abstract data into coding databases.
• Participate in coding audits and provide training feedback.
• Meet department production and quality standards for DRG coding.
• Maintain current medical terminology knowledge and coding guidelines.
• Clarify physician documentation as needed and interface with UCSF Health staff.

Skills

ICD-10-CM

ICD-10-PCS

DRG coding

Medical terminology

Coding audits

Documentation review

Tools

Coding databases

Job description

Health Information Coder 3, Per Diem

The Health Information Coder III 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

1. Retrieve and analyze comprehensive medical records and information systems for appropriate documentation and follow-up as appropriate.
2. Evaluate full episode of care of clinical data for inpatient cases and assign appropriate codes using ICD-10-CM and ICD-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.
3. Accurately input codes and abstract data into current coding databases.
4. Participate in coding audits and coding educational sessions and provide feedback and training.
5. Meet or exceed department production standards for the DRG coding level.
6. Meet or exceed department quality standards for the DRG coding level.
7. Maintain knowledge of current medical terminology, disease processes, anatomy & physiology, and current DRG coding guidelines.
8. Follow-up and clarify physician documentation (dictation and clinical notes).
9. Report to a lead or manager.
10. Interact with internal and external UCSF Health staff and customers.
11. Satisfactory time and attendance

Other Functions and Responsibilities

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

The final salary and offer components are subject to additional approvals based on UC policy.

Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement.

The hourly rate for this role is $70.02 (Hourly Rate).

To learn more about the benefits of working at UCSF, including total compensation, please visit: https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html