Health Information Services Coder I/II - Full-Time - Physician Enterprise

Kern Medical has been a community cornerstone since its founding in 1867. Today, we are an acute care teaching center with 222 beds, offering the only advanced trauma care between Fresno and Los Angeles. Kern Medical offers a range of primary, specialty, and multi-specialty services including high-risk pregnancy care, inpatient psychiatric services integrated with county mental health programs, and a growing network of outpatient clinics providing personalized patient-centered wellness care.  Kern Medical cares for 15,500 inpatients and 125,000 clinic patients a year.

Career Opportunities within Kern Medical include many benefits such as: 

• New Hire Premium: 6% of base rate of pay, matched up to 6% if contributed to Deferred Compensation Plan.
• A Comprehensive Benefits Package: includes Holidays, Paid Time Off, Retirement, Medical, Dental, Vision and Life Insurance.

Position: Health Information Services Coder I/II - Full-Time - Physician Enterprise 

Compensation

The estimated pay for this position is $23.4094 to $34.2817. The rates shown include a 6% premium pay (base= $-$ plus 6%). This reflects only a portion of the total compensation package for this position. Additional compensation may be available for this role through differentials, incentives, and bonuses. In addition, this position may be eligible for participation and company contributions into the Kern County Employees’ Retirement Plan.

Job Description 

Under supervision and on an assigned shift, is responsible for the review of inpatient, outpatient and emergency department medical record information and converting diagnosis and treatment procedures into codes for abstracting medical information according to procedures specified by Office of Statewide Health Planning and Development for reimbursement. 

DISTINGUISHING CHARACTERISTICS: Assignments involve routine to complex coding and abstracting functions, performed under close to limited supervision.

Level I: 

Essential Functions: 

• Codes and abstracts routine to complex patient medical record information according to the International Classification of Diseases Clinical Modification Systems (ICD) and the current procedure terminology (CPT) Manual and coding conventions and guidelines as established by the Coding Clinic and Office of Statewide Planning Health Department (OSHPD) reporting requirements.
• Assists with statewide Office of Statewide Health Planning Department (OSHPD) reporting by determining accurate identification of the Diagnostic Related Group (DRG) for proper reimbursement.
• Assists in compiling statistical data for hospital reporting.
• Assists in training less experienced coders.
• Reviews medical record documentation/information and verifies coding and DRG assignments in response to billing requests.
• Responds to authorized requests from agencies, administration  and individuals regarding DRG, coding questions or concerns. Maintains a working knowledge of current guidelines and regulations affecting code assignments through continuing education sessions and approved references such as journals, workshops and teleconferences.
• Performs other job related duties as required.

Level II:

Essential Functions:

• Codes and abstracts complex patient medical record information according to the International Classification of Diseases Clinical Modification Systems (ICD) and the current procedure terminology (CPT) Manual and coding conventions and guidelines as established by the Coding Clinic and Office of Statewide Planning Health Department (OSHPD) reporting requirements.
• Assists with statewide Office of Statewide Health Planning Department
• (OSHPD)reporting by determining accurate identification of the Diagnostic Related
• Group (DRG) for proper reimbursement.
• Assists in compiling statistical data for hospital reporting.
• Assists in training less experienced coders.
• Reviews medical record documentation/information and verifies coding and DRG
• assignments in response to billing requests.
• Responds to authorized requests from agencies, administration and individuals regarding DRG, coding questions or concerns.
• Maintains a working knowledge of current guidelines and regulations affecting code.
• Assignments through continuing education sessions and approved references such as journals, workshops and teleconferences.
• Performs other job-related duties as required.

Employment Standards: 

Level I:

One year of diagnostic and procedure coding experience in a hospital, health care facility, or physician's office. 

OR

Completion of a medical coding program whereby the necessary skills were obtained to successfully perform the essential functions of the job. 

Level II:

Three years of diagnostic and procedure coding experience in a hospital, health care facility or physician's office. 

OR

Current registration as a Certified Coding Specialist (CCS) by the American Health Information Management Association.

Knowledge of: Standards and regulations pertaining to the maintenance of patient medical records; medical records coding systems; medical terminology; anatomy and physiology and study of diseases; health information systems for computer application to medical records.

Ability to: Review medical record information, assign codes to diagnosis and procedures; utilize the ICD classification system and CPT conventions to code medical record entries; abstract information from medical records in accordance with defined regulations; read medical record notes and reports; set accurate Diagnostic Related Groups; comply with the American Health Information Management Association's Code of Ethics and Standards of Ethical Coding and applicable Uniform Hospital Discharge Data Set (UHDDS) standards; use computers and various software to accomplish work. 

A background check will be conducted for this classification.

Salary : $23 - $34