Health Information Coder II
Company: Kaiser Permanente
Location: Oakland
Posted on: May 27, 2023
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Job Description:
Job Summary:
Under indirect supervision, is responsible for accurate coding of
all inpatient, and outpatient services, procedures, diagnoses and
conditions, working from the appropriate documentation in the
medical record. Classification systems include ICD-9-CM, CPT, HCPCS
as well as other specialty systems as required by diagnostic
category. All work is carried out in accordance with the rules,
regulations and coding conventions of the American Hospital
Association (Coding Clinic), ICD9, CMS, OSHPD, and Kaiser coding
guidelines. As needed, Coders II may assist and be a resource for
data integrity for other employees who need clarification and
assistance in coding.
Positions assigned to this classification are differentiated from
those assigned to the Hospital Coder I classification in that only
the former are typically characterized by the performance of a
higher, more complex and responsible level of work generally
associated with - but not limited to - the coding of in-patient
Medicare medical records/data. Coders II also differ from Coders I
in the type and amount of supervision received; responsibility for
data comprehensiveness and quality assurance; direction provided to
other staff; data analysis, knowledge of procedures related to the
sequencing of diagnoses and interventions, as well as data
management policies and procedures; required quantity and quality
performance standards.
Essential Responsibilities:
Review medical records to identify diagnoses/procedures.
Independently organizes and prioritizes all work to ensure that
records are coded in timeframes that will assure compliance with
regulatory requirements. Reviews DRG discrepancies from the fiscal
intermediary to ensure the appropriate per case DRG assignment.
Demonstrates a comprehensive, expert-level of knowledge of all
procedures concerning the sequencing of diagnoses, procedures such
as but not limited to those outlined in ICD-9-CM, CPT, Uniform
Hospital Discharge Data Set, Medicare guidelines and other
appropriate classification systems. Demonstrates knowledge of
anatomy and physiology to interpret general medical classifications
for coding discharge data Including the most complicated
encounters/cases.
Assigns Codes. Codes all diagnostic and operative information from
the medical record using ICD-9-CM, CPT and HCPCS coding
classification systems and independently quality checks own work.
Selects the DRG for each inpatient case. Optimizes hospital payment
legitimately and ethically by utilizing approved coding guidelines
and conventions.
Verifies and abstracts, all medical data from the record to
complete a data abstract on each hospital encounter. Corrects data
as appropriate. Ensures that all data abstracted is consistent with
guidelines outlined by TJC, OSHPD and CMS, regional and local
policy. Completion of Medical Records Interacts with physicians to
clarify and accurately document patient diagnostic and procedural
information.
Enters patient information into the computerized inpatient and
outpatient medical record databases, ensuring the accuracy and
integrity of the medical record abstract data prior to transmitting
case to Government Reimbursement for billing. Ensures timely record
availability by meeting established coding and abstracting
productivity standards.
Independently conducts medical record documentation auditing to
monitor physician compliance with regulatory requirements i.e.,
Physician Review Project. Confidentiality/Security of Systems o
Maintains and complies with policies and procedures for
confidentiality of all patient records. Demonstrates knowledge of
security of systems by not sharing computer logons.
Other Duties Answers the telephone promptly and identifies
themselves and the department. Acts as an expert resource person to
other coders and personnel in other hospital departments regarding
coding questions and issues. Other duties as assigned by
supervisors. Supervisory Responsibilities: This job has no
supervisory responsibilities, but may provide guidance and
assistance to other coders.
Basic Qualifications:
Experience
Education
Completion of classes in medical terminology, anatomy and
physiology, ICD-9 and CPT coding conventions, and disease process
from an accredited program.
Must have high school diploma or GED.
License, Certification, Registration
Additional Requirements:
Demonstrated ability to understand the clinical content of a health
record, including the most complicated records.
Must also be able to communicate with physicians in order to
clarify diagnoses/procedures and sequencing of diagnoses.
Ability to demonstrate knowledge of and utilize auditing skills
related to coding quality and compliance.
Must be able to meet quantity and quality standards established for
Coders II.
Must be able to pass Kaiser coding test at ___%.
Basic PC skills. Must maintain a minimum of ten (10) CE units
annually.
Must maintain current coding credential.
Will abide by the AHIMA coding code of ethics.
Physical and Mental Demands: Ability to sit for long periods of
time.
Ability to lift, push or pull 11 to 20 pounds.
Occasional bending, stooping, kneeling, crouching, reaching.
Ability to withstand the pressure of continual deadlines and
receipt of work with variable requirements.
Ability to concentrate and maintain accuracy in spite of frequent
interruptions.
Manual dexterity.
Preferred Qualifications:
COMPANY: KAISER
TITLE: Health Information Coder II
LOCATION: Oakland, California
REQNUMBER: 1171246
External hires must pass a background check/drug screen. Qualified
applicants with arrest and/or conviction records will be considered
for employment in a manner consistent with Federal, state and local
laws, including but not limited to the San Francisco Fair Chance
Ordinance. All qualified applicants will receive consideration for
employment without regard to race, color, religion, sex, national
origin, sexual orientation, gender identity, protected veteran, or
disability status.
Keywords: Kaiser Permanente, Oakland , Health Information Coder II, Healthcare , Oakland, California
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