Health Information Coder II

4 weeks ago


San Francisco, California, United States University of California , San Francisco Full time
Job Summary

The Health Information Coder II is a key role in our organization, responsible for utilizing the ICD-10-CM, ICD-10-PCS, and CPT classification systems to code acute academic, teaching same-day surgery cases, special procedure cases, observation cases, and any non-office-procedure cases.

Cases are coded to comply with official guidelines for coding and reporting, practice standards, and code of ethics for HIMS coders. Abstracted data is used to support clinical decision-making and quality improvement initiatives.

Duties and Essential Job Functions
  • Retrieve and analyze comprehensive medical records and information systems for accurate documentation and follow-up.
  • Evaluate full episodes of care for ambulatory surgery cases, special procedures cases, observation cases, and any non-office procedure cases, assigning appropriate codes using ICD-10-CM, ICD-10-PCS, and CPT classification systems.
  • Meet external requirements for HCAI, HCFA, The Joint Commission, NCQA, and payor data requirements.
  • Accurately input codes and abstract data into current coding databases.
  • Participate in coding audits and coding educational sessions, providing feedback and training.
  • Meet or exceed department production standards for the coding level.
  • Meet or exceed department quality standards for the coding level.
  • Maintain knowledge of current medical terminology, disease processes, anatomy, and physiology, as well as current coding guidelines.
  • Follow up and clarify physician documentation (dictation and clinical notes).
  • Report to a lead or manager.
  • Interact with internal and external UCSF Health staff and customers.
  • Satisfactory time and attendance.
Other Functions and Responsibilities
  • Demonstrate understanding of the coding mission within UCSF Health.
  • Demonstrate understanding of coding, AR, and data submission information flow.
  • Ability to solve problems and troubleshoot computer issues.
  • Perform data searches.
  • Maintain patient confidentiality and IT security.
  • Treat others with respect and work well on a team.
  • As requested, train others.
  • Follow safety and infection control guidelines.
  • Maintain equipment and work area.
  • Comply with the UCSF Health dress code.
  • Other duties as assigned.


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