Patient Records Abstractor II - Remote - 141045

University of California - San Diego Medical Centers; United States; Remote; USD 65,000 - 86,000; Full time

Job summary

UC San Diego Health in the United States seeks a Patient Abstractor to analyze medical records, identify documentation deficiencies, and ensure compliance with The Joint Commission and Title 22 regulations. The role coordinates with HIM, clinical staff, and coding teams to facilitate timely record completion and accurate RVU-related billing.

The position involves routing deficiency notifications, maintaining MPI and ROI workflows, and troubleshooting electronic signature systems while supporting

Qualifications

• AHIMA or AAPC accredited program completed.
• Experience in medical record coding and documentation.
• Knowledge of HIM policies and Revenue Cycle processes.
• Familiarity with HIPAA and CMS guidelines.

Responsibilities

• Review and analyze medical records to identify documentation deficiencies and ensure regulatory compliance.
• Assign deficient documentation and monitor completion in the EHR and legacy systems.
• Support physician billing and coding functions and assist with RVU-related tasks.
• Route deficiency notifications between HIM, clinical staff, and coding teams.
• Troubleshoot electronic signature systems and coordinate with IT/operations as needed.
• Assist with MPI maintenance, scanning/indexing, and Release of Information processes.

Education

AHIMA or AAPC accredited Health Information Tech/Management or Coding Program

Tools

Epic

Job description

Candidates hired into this position may have the ability to work remotely.

DESCRIPTION

UC San Diego Health's Revenue Cycle department supports the organization’s mission to deliver outstanding patient care and to create a healthier world - one life at a time. We are a diverse, patient-focused, high-performing team with a commitment to quality, collaboration, and continuous improvement that enables us to deliver the maximum standard of care to our patients. We offer challenging career opportunities in a fast-paced and innovative environment and we embrace individuals who demonstrate a deep passion for problem-solving and customer service.

The Patient Abstractor reviews and analyzes medical records to identify documentation deficiencies and ensure compliance with The Joint Commission (TJC) standards, Title 22 regulations, Medical Staff Bylaws, Rules and Regulations, and Health Information Management (HIM) policies and procedures. This role serves as a primary liaison between deficiency analysis staff, management, clinical providers, and other key stakeholders to facilitate timely and accurate completion of medical records.

The Patient Abstractor assigns required documentation and dictation deficiencies, monitors record completion through the electronic health record (EHR) and legacy systems, and tracks outstanding deficiencies to ensure responsible providers meet record completion requirements within established timeframes. The role also supports physician billing and coding functions by assisting with the accurate assignment of billing-related documentation, which directly impacts physician Relative Value Units (RVUs).

Additionally, the Patient Abstractor ensures the appropriate routing of deficiency notifications and communications to providers and their respective departments. Acting as a key point of contact between HIM, clinical staff, and coding teams, this position helps resolve documentation and workflow-related issues while supporting effective communication across departments.

This role is responsible for troubleshooting electronic and technical issues related to electronic signature systems and coordinating resolution efforts with the appropriate technical and operational teams. Success in this position requires strong verbal and written communication skills, the ability to build collaborative relationships, and the capacity to clearly explain complex documentation, compliance, and workflow requirements to diverse audiences.

The Patient Abstractor may also provide support for other HIM functions, including maintenance of the Master Patient Index (MPI), scanning and indexing of patient records, document imaging workflows, and Release of Information (ROI) processes, as needed to support departmental operations and organizational goals.

MINIMUM QUALIFICATIONS

• Graduation from High School or a GED with a demonstrated knowledge of the applicable medical terminology.
• Successful completion of AHIMA or AAPC accredited Health Information Tech/Management or Coding Program.
• Certified Professional Coder (CPC-A) or credentialed by AHIMA (RHIT)
• Experience coding physician, outpatient, inpatient, ancillary or surgical claims.
• Prior experience working in a hospital/physician office environment.

PREFERRED QUALIFICATIONS

• Two (2) years of related hospital clerical experience; one of which must be in the type of work to be performed; or an equivalent combination of education and experience.
• Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification.
• Professional fee coding certification, such as CPC or CCS-P.
• Healthcare Environment Experience.
• Experience in Release of Information of medical records.
• Familiar with HIPAA and CMS Medicare Guidelines.
• Familiar with TJC (Joint Commission) and Title 22 Regulations.
• Experience with chart analysis in Epic.
• Experience working with transcription vendors.
• Experience working with Patient Identity/Data Integrity.

SPECIAL CONDITIONS

• Must be able to work various hours and locations based on business needs.
• Employment is subject to a criminal background check and pre-employment physical.

Pay Transparency Act

Annual Full Pay Range: $64,937 - $85,650 (will be prorated if the appointment percentage is less than 100%)

Hourly Equivalent: $31.10 - $41.02

Factors in determining the appropriate compensation for a role include experience, skills, knowledge, abilities, education, licensure and certifications, and other business and organizational needs. The Hiring Pay Scale referenced in the job posting is the budgeted salary or hourly range that the University reasonably expects to pay for this position. The Annual Full Pay Range may be broader than what the University anticipates to pay for this position, based on internal equity, budget, and collective bargaining agreements (when applicable).