Position Description

Promotional Opportunity Only: Applications received by the final filing date of Friday, July 05, 2024 at 11:59pm will be guaranteed consideration. The eligible list established from this recruitment may be used to fill future per-diem and permanent vacancies as they arise. Exam#P24/50T06/06SS.

Examples of Duties

• Depending upon assignment, reviews and codes inpatient and/or outpatient medical record information; assigns codes using the International Classification of Diseases Manual ICD 10-CM the American Medical Association’s Current Procedural Terminology (CPT) manual, and/or the Healthcare Common Procedure Coding System (HCPCS) codes and modifier assignments; establishes Ambulatory Payment Classification (APC) and/or Diagnosis Related Group (DRG) group appropriateness; identifies and codes secondary diagnoses and/or procedures; ensures compliance with all APC and/or DRG mandates and reporting requirements
• Abstracts Department of Health Care Access and Information (HCAI) data elements and assists the HIM Coding Supervisor with correcting and submitting data
• Monitors Medicare and other DRG paid bulletins and manuals, and reviews the current Office of the Inspector General (OIG) work plans for DRG risk areas
• Evaluates the quality of clinical documentation on a continuous basis to identify incomplete or inconsistent documents for inpatient and/or outpatient encounters that impact the code selection and resulting APC/DRG groups and payment; brings concerns to the attention of the HIM Coding Supervisor and/or medical staff for resolution
• Maintains knowledge of current and required coding certifications as appropriate
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association; reports areas of concern to the HIM Coding Supervisor
• Assists the HIM Coding Supervisor by serving as a facility representative for DRGs and/or APCs by attending coding and reimbursement workshops and bringing back information as appropriate; communicates any DRG/APC updates published in third-party payer newsletters, bulletins and/or provider manuals; shares information with facility staff as directed
• Assists the HIM Coding Supervisor in performing data quality reviews on inpatient records to validate the International Classification of Diseases Manual (ICD-10-CM), and other codes; verifies Diagnosis Related Group (DRG) group appropriateness; checks for missed secondary diagnoses and procedures and ensures compliance with all DRG mandates and reporting requirements; monitors Medicare and other DRG paid bulletins and manuals, and reviews the current Office of the Inspector General (OIG) work plans for DRG risk areas
• Assists the HIM Coding Supervisor in performing data quality reviews on outpatient encounters to validate the ICD-10-CM, the Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS) Level II code and modifier assignments; verifies Ambulatory Payment Classification (APC) group appropriateness; checks for missed secondary diagnoses and/or procedures; ensures compliance with all APC mandates and outpatient reporting requirements; monitors medical visit code selection against facility specific criteria for appropriateness; assists in the development of such criteria as needed
• Monitors unbilled account reports for outstanding services or un-coded discharges to reduce accounts receivable days for inpatients and/or outpatients
• Stays informed of transaction code sets, Health Insurance Portability and Accountability Act (HIPAA) requirements and other future issues impacting the coding function; keeps abreast of new technology in coding and abstracting software and other forms of automation
• Demonstrates competency in the use of computer applications, particularly the coding and abstracting software and hardware currently in use by the Health Information Management division
• Assists the HIM Coding Supervisor in performing periodic claim form reviews to check code transfer accuracy from the abstracting software and the charge master; may serve on a charge master maintenance committee
• Complies statistics and prepares/maintains a variety of records and reports; finalizes attending physician attestations and obtains signatures; researches and locates missing data and records needed for coding and abstracting; retrieves files and records

Examples of Experience/Education/Training

• Medical record keeping principles and practices; the nature and uses of medical records charges; basic medical terminology, anatomy, and physiology
• Basic function of a hospital medical records division; legal aspects of medical record administration
• ICD-10-CM, CPT, and HCPCS Level II coding systems
• The APC structure and regulatory requirements
• Basic keyboard operations and the operation of standard office equipment; standard business computer hardware and software
• The business and professional relationships and ethics involved among hospitals, physicians and patients
• The current Diagnostic and Statistical Manual of Mental Disorders (e.g., DSM IV-TR)
• Current hospital reimbursement systems and associated regulatory review practices
• Governmental and Joint Commission (TJC) standards for medical records
• States, sequence, progression and description of disease

• Read, interpret and evaluate complex technical reports and information
• Understand and apply anatomical, physiological and medical terminology
• Operate a personal computer
• Maintain records and compile statistics
• Communicate clearly and concisely, both orally and in writing; prepare reports and other written communications
• Provide excellent public relations and courteous customer service; establish and maintain cooperative working relationships with others including physicians, nurses, administrators, managers, vendors, contractors and other healthcare industry personnel
• Interpret both outpatient and inpatient medical records to assign diagnostic codes and prepare medical record abstracts
• Understand disease processes, advanced medical terminology, diagnostic descriptions and procedures
• Evaluate the quality, completeness and accuracy of medical records
• Work with physicians and others to ensure complete and accurate information and optimal reimbursement based on coding and abstracting of medical records

Additional Information

• Natividad requires that all incumbents pass a pre-employment physical/medical assessment.
• Natividad will conduct a thorough background and reference check process which includes a Department of Justice fingerprint check.
• Employees who drive on County business to carry out job related duties must possess a valid CA Driver License for the class vehicle driven and clean driving record.
• Employees must have and show their original Social Security Card and a valid CA Driver License or CA State ID prior to the first day of work.
• Incumbents may be required to work all shifts, including weekends and holidays;
• Incumbents may be required to work with potentially hazardous and infectious substances.

• If you believe you possess a disability that would require test accommodation, please contact the Personnel Analyst for Natividad at (831) 783-2711.
• Employment is contingent upon acceptable documentation verifying identity and authorization for employment in the United States.
• If you are hired into this classification in a temporary position, your salary will be hourly and you will not be eligible for benefits.