Patient Records Abstractor 4 Per Diem

#CA-SS

Under the general direction of the HIM Inpatient Coding Supervisor the incumbent is required to review medical record documentation for all ED patient encounters, identify all billable services and discuss with the physician/provider when discrepancies occur between coding and documentation. Responsibilities include collecting and analyzing documentation, assigning appropriate CPT evaluation/management and procedure codes, ICD-10 diagnosis and APC general ledger codes in order to generate billing for services rendered. Prepares and enters charges to the online charge entry systems. Incumbent will ensure compliance to all federal, state and carrier specific rules, regulations and requirements, related to professional fee and technical services are followed.

Apply By Date March 20, 2025 by 11:59PM

Minimum Qualifications - For full consideration, applicants are encouraged to upload license and/or certification if required of the position

• American Health Information Management Association (AHIMA) Certified Coding Specialist-Physician-based (CCS-P) or Certified Coding Specialist (CSS), or American Association of Professional Coders (AAPC) Certified Professional Coder (CPC) Certification
• American Health Information Management Association (AHIMA) Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification may also be appropriate in lieu of CCS-P, CCS or CPC certifications.
• Experience with and instructional notations and conventions of ICD-10-CM, APC and CPT classification system.
• Several years ED Pro Fee and Facility Coding
• Ability to read handwritten and transcribed documents in the medical record, interpret information, and enter complete and accurate data into an on-line encoding system.
• Comprehensive knowledge of medical diagnostic and procedural terminology required.
• College level understanding of disease processes, anatomy and physiology necessary to assign accurate codes using the ICD-10 CM and CPT coding conventions.
• Knowledge of Federal, State and local government regulations and requirements which pertain to patient care information and requirements for a complete medical record for deficiency chart analysis.
• Knowledge of third-party payer reimbursement requirements and an understanding of multi-medical specialties, encounters, and procedures in acute care, EDand ambulatory care settings.
• Ability to communicate technical and clinical information concerning patient care and classification systems at different levels, i.e. physicians, ancillary, and administrative personnel.
• Ability to apply policies and procedures regarding data security and confidentiality to protect the inappropriate release of information.
• Ability to exercise judgement with minimal supervision.
• Ability to be flexible & follow many different guidelines that change annually.
• Ability to assume responsibility for compilation of clinical data related to inpatient and outpatient encounters including diagnoses, procedures, physicians and services.
• Remains current with periodic updates of all coding manuals and guidelines in accordance with Federal, State and local regulations.
• Ability to manage time schedules, deadlines, multiple requests/priorities and to maintain productivity.
• PHYSICAL SKILLS REQUIRED:Ability to handle the stress and pressures of a job where there is noise from conversation and office machines.
• Ability to read text for long period of time from a book, medical record and/or computer terminal.
• Must be able to work occasional overtime.
• Knowledge of and ability to follow the detailed guidelines related to their use in assigning single, and sequencing multiple, diagnosis and procedure codes for appropriate reimbursements and data collection.

Key Responsibilities

• 90% - REVIEWS, ABSTRACTS AND CODES INPATIENT,OUTPATIENT,AND AMBULATORY SURGERY RECORDS TO ENSURE DATA QUALITY AND TO OPTIMIZE REIMBURSEMENT
• 5% - PROVIDE SUPPORT TO THE CODING UNIT
• 5% - PARTICIPATES IN EDUCATIONAL EXPERIENCES CONCERNING CODING AND ABSTRACTING ISSUES

Department Overview

The Health Information Management (HIM) Department is a critical part of the healthcare organization, dedicated to improving patient care, supporting research, and facilitating education through the efficient management of medical records and clinical databases. The department, which consists of over 200 Full-Time Equivalents (FTEs) across diverse units, is responsible for ensuring the accuracy, accessibility, and compliance of patient information, which is crucial for clinical decision-making, billing accuracy, and regulatory adherence.

The department includes key groups such as Inpatient and Outpatient Clinical Documentation Integrity (IP/OP CDI), All Coding Operations, the CDI Coding Quality Analyst Group, the HIM Clinical Analyst Team, and the Provider Advocate Team. Each of these teams plays a specialized role in supporting the organization's health information needs.

IP/OP CDI focuses on ensuring that clinical documentation accurately reflects the complexity and severity of patient care, contributing to appropriate coding, billing, and reimbursement. All of Coding Operations ensures that all patient records are coded accurately according to industry standards and regulatory requirements, supporting billing processes and ensuring compliance. The CDI Coding Quality Analyst Group is responsible for monitoring and improving the quality of clinical documentation and coding processes to ensure accuracy and efficiency. The HIM Clinical Analyst Team focuses on the analysis and optimization of clinical data systems, ensuring that health information is easily accessible and accurate across the organization in collaboration with other department data analysts. The Provider Advocate Team collaborates directly with physicians and other clinical staff to ensure accurate documentation and smooth integration of clinical data into patient records.

Together, these teams ensure that the department not only supports day-to-day clinical operations but also plays a key role in broader strategic initiatives. The HIM Department ensures that data integrity is maintained, healthcare regulations are followed, and operational workflows are optimized to support patient care and organizational efficiency. Through this multidisciplinary approach, the HIM Department significantly contributes to the organization's mission of delivering high-quality healthcare.

POSITION INFORMATION

• Salary or Pay Range: $56.21
• Salary Frequency: Hourly
• Salary Grade: 110
• UC Job Title: PAT RCDS ABSTRACTOR 4 PD
• UC Job Code: 004714
• Number of Positions: 1
• Appointment Type: Staff: Per Diem
• Percentage of Time: 20%
• Shift (Work Schedule): 7am-3:30pm
• Location: Remote Worksite (REMOTE)
• Union Representation: EX-Patient Care Technical
• Benefits Eligible: No
• This position is 100% remote

Benefits

Outstanding benefits and perks are among the many rewards of working for the University of California. UC Davis offers a full range of benefits, resources and programs to help you bring your best self to work, as well as to help you and your family achieve your health, wellness, financial and career goals. Learn more about the benefits below and eligibility rules by visiting either our handy Benefits Summary for UC Davis Health Employees or Benefits Summary for UC Davis Employees and our Benefits Page.

If you are represented by a union, benefits are negotiated between the University of California (UC) and your union and finalized in a contract. Read your bargaining unit's employment contract, stay abreast of current negotiations and learn about collective bargaining at UC: https://ucnet.universityofcalifornia.edu/labor/bargaining-units/index.html

* High quality and low-cost medical plans to choose from to fit your family's needs
* UC pays for Dental and Vision insurance premiums for you and your family
* Extensive leave benefits including Pregnancy and Parental Leave, Family & Medical Leave
* Paid Holidays annually as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
* Paid Time Off/Vacation/Sick Time as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
* Continuing Education (CE) allowance and Education Reimbursement Program as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
* Access to free professional development courses and learning opportunities for personal and professional growth
* WorkLife and Wellness programs and resources
* On-site Employee Assistance Program including access to free mental health services
* Supplemental insurance offered including additional life, short/long term disability, pet insurance and legal coverage
* Public Service Loan Forgiveness (PSFL) Qualified Employer & Student Loan Repayment Assistance Program for qualified roles
* Retirement benefit options for eligible roles including Pension and other Retirement Saving Plans. More information on our retirement benefits can be found here
* UC Davis cares about building a community, which is why we provide resources to enhance diversity, equity and inclusion as well as Employee Resource Groups (ERGs) to support our staff

Physical Demands

• Sitting - Continuous 6 to 8+ Hours

Mental Demands

• Sustained attention and concentration - Continuous 6 to 8+ Hours
• Complex problem solving/reasoning - Continuous 6 to 8+ Hours
• Ability to organize & prioritize - Continuous 6 to 8+ Hours
• Communication skills - Continuous 6 to 8+ Hours
• Numerical skills - Continuous 6 to 8+ Hours
• Constant Interaction - Frequent 3 to 6 Hours
• Multiple Concurrent Tasks - Continuous 6 to 8+ Hours

Work Environment

• UC Davis is a smoke and tobacco free campus effective January 1, 2014. Smoking, the use of smokeless tobacco products, and the use of unregulated nicotine products (e-cigarettes) will be strictly prohibited on any UC Davis owned or leased property, indoors and outdoors, including parking lots and residential space.
• Must be able to work occasional overtime.

Special Requirements - Please contact your recruiter with questions regarding which activities apply by position

• This is a critical position, as defined by UC Policy and local procedures, and as such, employment is contingent upon clearing a criminal background check(s) and may include drug screening, medical evaluation clearance and functional capacity assessment
• This position is designated as a mandated reporter under CANRA and UC policy, and employment is contingent on compliance with applicable policies, procedures and training requirements

Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.

Diversity, Equity, Inclusion and Belonging

At UC Davis, we're solving life's most urgent challenges to bring a fuller, healthier, and more resilient world within reach. We grow from every challenge we take on and we don't just maintain - we improve. We recognize that creating an inclusive and intellectually vibrant organization means understanding and valuing both our individual differences and our common ground. The most comprehensive solutions come from the most diverse minds and you belong here. As you consider joining UC Davis, please explore our Principles of Community, our Clinical Strategic Plan and strategic vision for research and education, and our latest efforts to outgrow the expected. The University of California, Davis is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age or protected veteran status.

For the University of California's Affirmative Action Policy, please visit: https://policy.ucop.edu/doc/4010393/PPSM-20

For the University of California's Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

Because we want you to be seen, our recruiting process at UC Davis fosters authenticity, diversity, and inclusion. Studies have shown that some people may not apply to jobs unless they meet every single qualification. Each unique role at UC Davis has a set of requirements and you could be perfect for this role, or you could be perfect for the next role! Don't meet all the requirements? We still encourage you to apply! #YouBelongHere

To learn more about our background check program, please visit: https://hr.ucdavis.edu/departments/recruitment/ucd/selection/background-checks