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County of Santa Clara · 4 hours ago

Coder II - Trauma Administrative Services Department

Santa Clara County, CA

Full-time

Onsite

Entry, Mid Level

2+ years exp

The County of Santa Clara is seeking a Coder II for the Trauma Administrative Services Department. The role involves performing moderately complex coding and abstracting of medical service records, ensuring compliance with federal and state coding guidelines, and maintaining coding certifications.

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Comp. & Benefits

Responsibilities

Reviews, abstracts, and codes medical-record data using coding systems such as ICD-9-CM, CPT-4, and HCPCS or subsequent adaptations

May perform coding review or audit of provider charges submitted electronically, charge ticket, or electronic file

Provides CPT and ICD-9 codes to unit and other staff when required

Records the coding information into the appropriate charge system such as a computer system, paper-charge ticket, and/or electronic file

Reviews and abstracts procedural, diagnostic services, and/or facility level of services from the medical record and assigns the appropriate coding

Identifies and assigns diagnosis, CPT procedural codes, HCPC codes or facility level of service utilizing the current adaptation of the International Classification of Diseases (ICD-9-4), CPT-4, HCPC or LOS

May assign unique coding required by MediCal or other third-party payers when different than the industry standard by CMS

Applies knowledge of anatomy, physiology, disease processes, and medical terminology to accurately assign and sequence the procedural coding, diagnoses, or HCPC codes

Accurately assigns Medicare Severity Diagnosis Related Group (MSDRG) and Ambulatory Payment Classification (APC) number or other coding classifications

(In Diagnostic Imaging Unit) Reviews various radiology reports for appropriate CPT codes and assigns codes accordingly using ICD-9 code set or subsequent adaptation (such as ICD-10) and performs other coding-related duties pertaining to diagnostic imaging

Participates in the development of policies and procedures; supports the implementation of departmental policies and procedures

Reviews Coder I work for completeness and correctness, and assists in the orientation of new staff to the unit

Reviews and resolves charge errors and/or coding discrepancies

Follows department policy regarding notification of incomplete or missing information from the patient record

Communicate with other departments and providers regarding account clarification and corrections

Maintains HIPPA confidentiality, privacy, and security of all patient-related information

Maintains harmonious work relationships

May be assigned as a Disaster Service Worker, as required

Performs other related work as required

Qualification

Coding certificationTrauma data managementICD-9-CM codingCPT-4 codingHCPCS codingMedical terminologyData analysisCommunication skillsOrganizational skillsAttention to detail

Required

Possession of a current, applicable coding certification

Possession of a Certified Abbreviated Injury Scale Specialist (CAISS) certification

Sufficient education, training, and experience to demonstrate the ability to perform the above tasks

Possession of a high school diploma (or GED equivalent)

Possession of a CCA, CMC (PMI) or CCS or RHIT or RHIA or CPC (AAPC) certification

Two (2) years experience as a medical coder which included coding outpatient and/or inpatient records using ICD-9 diagnosis (or subsequent ICD adaptation), procedures CPT codes, HCPS coding system

Maintain coding competency regarding procedural, diagnosis, HCPC codes and LOS facility charges

Strong understanding of coding, compliance and regulatory payer guidelines

Complete the required Continuing Education Units (CEUs) annually to ensure certifications remain active and in good standing

Knowledge of coding guidelines, abstracting, and medical terminology to utilize and assign appropriate coding: current ICD-9-CM and CPT-4, HCPCs or subsequent adaptations

Knowledge of computer encoding software programs, online tools, coding references and websites

Knowledge of the principles and practice of accurate and compliant abstracting and coding techniques

Knowledge of comprehensive medical terminology, anatomy and physiology, and disease processes related to medical specialties

Knowledge of components and format of the hard copy and/or electronic version of medical record

Knowledge of English grammar, punctuation, spelling, and general English usage

Knowledge of computerized patient data systems

Ability to read and comprehend the elements of a medical chart, medical-record notes, and reports

Ability to analyze, code, and abstract moderately-complex technical data from medical records

Ability to identify missing elements, inferred between procedural and treatment relationships

Ability to properly sequence abstracted/coding information from a medical record

Ability to read and understand medical record notes and reports and accurately classify all diagnoses and procedures

Ability to effectively use the various computer systems necessary to perform job functions

Ability to communicate clearly, both orally and in writing, with medical and nursing staff, employees at all levels of the organization, patients, and the public

Ability to plan, organize, and prioritize work, and meet deadlines

Ability to reason logically, and use sound judgment in the performance of duties