JOB SUMMARY

The Health Information Coder III PD is a senior-level inpatient coder with advanced 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.

This is a per diem position with no set schedule.

OTHER FUNCTIONS AND RESPONSIBILITIES

• Demonstrate understanding of DRG coding mission within UCSF Health.

• Demonstrate understanding of DRG coding, AR, and data submission information flow.

• Ability to solve problems and troubleshoot computer issues.

• Perform data searches.

• Maintain patient confidentiality and IT security.

• Treat others with respect and work well on a team.

• As requested, train others.

• Follow safety and infection control guidelines.

• Maintain equipment and work area

• Comply with the UCSF Health dress code.

• Other duties as assigned.

DEPARTMENTAL OVERVIEW

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.

REQUIRED QUALIFICATIONS

• High school graduation.
• Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) certification
• 3+ years’ experience inpatient DRG coding and abstracting.
• Advanced knowledge of medical terminology, medical abbreviations, disease processes, anatomy and physiology.
• Advanced knowledge of the ICD-10-CM, ICD-10-PCS and CPT classification systems.
• Must pass the initial knowledge assessment test with a score of 80% or must have 6 months recent inpatient DRG coding experience with UCSF with 80% accuracy rate.
• Must meet daily production requirement with minimal accuracy rate of 95%.
• Advanced EHR and encoder skills
• Advanced computer skills, including Windows, Word and Excel.
• Proven excellent communication and cooperative skills.
• Ability to analyze information, make decisions and exercise independent judgment.
• Ability to follow written directions.
• Ability to prioritize work and manage time effectively.

• Ability to meet deadlines and perform well under pressure.

REQUIRED LICENSES/CERTIFICATIONS

• Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) certification

  PREFERRED QUALIFICATION

• Knowledge of HIMS database systems.
• Knowledge of HIMS procedures.