Patient Records Abstractor 4

UC Davis Clinical and Translational Science Center; Sacramento (CA); Remote; USD 60,000 - 80,000; Full time

Job summary

Join a leading health information management department as a Patient Records Abstractor 4. This role involves abstracting and coding medical services, ensuring compliance with regulations, and optimizing reimbursement. Ideal candidates will have coding certifications and experience in acute care settings. This full-time position offers remote work with comprehensive benefits, emphasizing diversity and inclusion.

Benefits

Health plans

Paid leave

Continuing education

Wellness programs

Retirement options

Qualifications

• Several years of acute care coding experience required.
• Familiarity with CMS, JCAHO documentation requirements.
• Ability to interpret medical records and enter data accurately.

Responsibilities

• Review and code inpatient, outpatient, and ambulatory surgery records.
• Support the coding unit.
• Participate in educational activities related to coding.

Skills

Effective communication

Data security

Judgment

Education

AHIMA Certified Coding Specialist

CCS-P

CPC

Tools

ICD-9-CM

CPT classification

DRG

APC

Job description

Join to apply for the Patient Records Abstractor 4 role at UC Davis Clinical and Translational Science Center

#CA-SS

The Patient Records Abstractor 4 (PRA) performs abstracting of medical services provided by UCDH and affiliates under the general direction of the Supervisor. The PRA identifies all billable services (IP Professional, Outpatient professional and facility, Hospital Service Departments, Freestanding, and Ancillary Services), CPT-4, ICD-10, and HCPCS codes for billing purposes to government agencies, insurance companies, and patients. The PRA is responsible for the accuracy of the procedure and diagnosis coding relative to documentation and standards. The PRA will ensure compliance with all federal, state, and carrier-specific rules, regulations, and requirements related to professional fee services.

Apply By Date: May 16, 2025 at 11:59PM

Minimum Qualifications

• AHIMA Certified Coding Specialist – Physician-based (CCS-P), CCS, AAPC Certified Professional Coder (CPC), or COC Certification.
• Several years of acute care, ED, and/or ASU coding experience, including DRG and APC assignment.
• Familiarity with OSHPD, UHDDS, CMS, JCAHO documentation requirements; knowledge of ICD-9-CM, DRG, APC, CPT classification systems.
• Ability to interpret handwritten and transcribed medical records and accurately enter data into encoding systems.
• Comprehensive knowledge of medical terminology, disease processes, anatomy, and physiology.
• Understanding of government regulations related to patient care information and medical records.
• Knowledge of third-party payor reimbursement requirements and multi-specialty medical procedures.
• Effective communication skills with physicians, staff, and administrators.
• Ability to apply data security and confidentiality policies.
• Judgment with minimal supervision, flexibility, and adherence to changing guidelines.
• Responsibility for compiling clinical data, staying current with coding updates, and managing time effectively.

Preferred Qualifications

• CCS-P or CPC certification highly preferred.

Key Responsibilities

• Review, abstract, and code inpatient, outpatient, and ambulatory surgery records to ensure data quality and optimize reimbursement (90%).
• Support the coding unit (5%).
• Participate in educational activities related to coding and abstracting (5%).

Department Overview

The Health Information Management Department supports patient care, research, and education through efficient management of medical records and databases. The department includes teams such as Inpatient/Outpatient CDI, Coding Operations, Quality Analysts, Clinical Analysts, and Provider Advocates, all working to ensure data accuracy, compliance, and operational efficiency.

Position Details

• Salary: $48.64 - $60.44 per hour
• Full-time, 100% remote, day shift
• Union: EX-Patient Care Technical
• Benefits eligible

Benefits

UC Davis offers comprehensive benefits, including health plans, paid leave, continuing education, wellness programs, retirement options, and more. Details available on the UC Davis benefits pages.

Physical & Mental Demands

Includes standing, walking, sitting, lifting, bending, and keyboard use; requires sustained attention, organization, communication, and handling multiple tasks.

Work Environment & Requirements

Includes a smoke-free campus, background checks, mandatory reporting, and compliance with policies. The role emphasizes diversity, equity, inclusion, and belonging.