Please note: this is a temporary assignment (3 months) with potential to extend. Fully remote.

UCSF's Temporary Employment Program (TEP) recruits and hires temporary employees for immediate clerical and technical support services to UCSF Departments and various off-campus locations. UCSF departments deploy temporary employees to work on special projects, fill in for regular employees who are on vacation or leave, or to temporarily fill a vacant position during recruitment. Frequently temporary employees become successful candidates for career and limited appointment positions.

The Health Information Coder III is a senior level inpatient coder with an advance knowledge and skill set to utilize the ICD-10-CM, ICD-10-PCS, CPT, HCPCS classification systems. The skill set extends to advanced knowledge and comprehension of code sequences into Diagnoses Related Groups. Cases are coded to comply with the official guidelines for coding and reporting, practice standards and code of ethics for HIMS coder.  Cases are abstracted according to UCSF Health policies and procedures.  The focus of coding and abstracting is on a range of all primary hospital services.

UCSF’s Health Information Management department maintains health records for all inpatient, outpatient, and same-day surgery services.  These records are protected under HIPPA and California state law, ensuring privacy and confidentiality.  The coding department at UCSF is responsible for translating detailed clinical documentation, such as diagnoses, procedures, and services into standardized alphanumeric codes that can be understood by all parts of the healthcare system.  Its main purpose is to ensure accurate communication, billing, compliance, and data use across hospitals, clinics, insurers, and public health agencies.

Responsibilities

• Retrieves and reviews comprehensive medical records and information from applicable systems to identify relevant clinical documentation and determine appropriate follow-up. 
• Evaluates the complete episode of care for inpatient cases and assigns accurate ICD-10-CM and ICD-10-PCS codes based on clinical documentation, diagnoses, procedures, and applicable coding guidelines. 
• Determines appropriate MS-DRG assignment based on the clinical data and coding of each inpatient case. 
• Ensures coding and data abstraction meet applicable external regulatory, accreditation, quality, and payer requirements, including HCAI, HCFA, The Joint Commission, NCQA, and other applicable data submission requirements.  
• Accurately enters codes and abstracts clinical and demographic data into applicable coding and database systems. 
• Participates in coding audits, educational sessions, and quality improvement activities; provides feedback and training as requested. 
• Consistently meets or exceeds departmental production standards established for the assigned DRG coding level. 
• Consistently meets or exceeds departmental quality and accuracy standards established for the assigned DRG coding level. 
• Maintains current knowledge of medical terminology, disease processes, anatomy and physiology, coding guidelines, and DRG methodologies. 
• Reviews and follows up on physician documentation, including dictation and clinical notes, to clarify clinical information necessary for accurate coding and DRG assignment. 
• Identifies and resolves coding and documentation discrepancies and escalates issues to the appropriate lead or manager when necessary. 
• Reports coding, workflow, or other operational concerns to the appropriate lead or manager. 
• Collaborates and communicates effectively with internal and external UCSF Health staff, providers, customers, and other stakeholders. 
• Demonstrates an understanding of the DRG coding mission within UCSF Health, including the relationship between DRG coding, accounts receivable (AR), and data submission processes. 
• Performs data searches and retrieves information from applicable systems to support coding, validation, and follow-up activities. 
• Troubleshoots basic computer and system-related issues and escalates technical issues as appropriate. 
• Maintains patient confidentiality and complies with all applicable privacy, information technology (IT) security, and data protection requirements. 
• Maintains satisfactory time and attendance in accordance with departmental and organizational expectations. 
• Treats others with respect and demonstrates effective teamwork, collaboration, and professionalism. 
• Provides training, education, and guidance to other staff members as requested. 
• Follows applicable safety and infection control guidelines. 
• Maintains equipment and ensures the work area is clean, organized, and safe. 
• Complies with UCSF Health dress code and other applicable organizational policies. 
• Performs other duties as assigned. 

Qualifications

Required:

• High school diploma or equivalent. 
• CCS, CIC, RHIT, or RHIA certification. 
• 10+ years of experience in inpatient DRG coding and abstracting. 
• Must successfully pass the initial knowledge assessment with a score of 80% or higher, or have at least six (6) months of recent inpatient DRG coding experience with UCSF and demonstrate an 80% accuracy rate. 
• Ability to meet or exceed daily production requirements while maintaining a minimum 95% accuracy rate. 
• Advanced proficiency with electronic health record (EHR) and encoder systems. 
• Advanced computer skills, including proficiency with Windows, Microsoft Word, and Microsoft Excel. 
• Excellent written and verbal communication skills and demonstrated ability to work collaboratively with others. 
• Strong analytical, problem-solving, and decision-making skills, with the ability to exercise independent judgment. 
• Ability to understand and follow written instructions and established procedures. 
• Strong organizational skills with the ability to prioritize work and manage time effectively. 
• Ability to meet deadlines and perform effectively in a fast-paced environment and under pressure. 
• Advanced knowledge of medical terminology, medical abbreviations, disease processes, anatomy, and physiology. 
• Advanced knowledge of ICD-10-CM, ICD-10-PCS, and CPT classification systems. 
• Knowledge of current inpatient DRG coding guidelines, methodologies, and applicable regulatory requirements. 
• Must pass pre-hire coding test.

REQUIRED LICENSES/CERTIFICATIONS

• CCS, CIC, RHIT, or RHIA certification.

Preferred:

• Knowledge of HIMS database systems. 
• Knowledge of HIMS procedures. 
• Academic Medical Center experience.