Health Information Coder Trainee
Company: Kaiser
Location: La Mesa
Posted on: January 18, 2023
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Job Description:
Under general supervision, responsible for coding medical
records, which typically are less complex and comprehensive such as
but not limited to: inpatient or outpatient diagnoses, conditions
and procedures. Working from the appropriate ICD-9-CM, ICD-10-CM,
and CPT, as well as other coding classification systems as required
by diagnostic/procedural category. All work is performed in
accordance with the rules, regulations, and coding conventions as
established by the American Hospital Association (Coding Clinic),
ICD-9-CM, ICD-10-CM, Official Coding Guidelines for Coding and
Reporting, CMS, OSHPD, and Kaiser Permanente
organizational/institutional coding guidelines - -Essential
Functions: - ---- Upholds Kaiser Permanente's Policies and
Procedures, Principles of Responsibilities, and applicable state,
federal, and local laws ------Reviews medical records to identify
diagnoses/procedures:--- Under general supervision/mentoring:---
Organizes and prioritizes all work to ensure that records are coded
in timeframes that will assure compliance with regulatory
requirements --- Demonstrates knowledge of all procedures
concerning the sequencing of diagnoses, procedures as outlined in,
but not limited to, ICD-9-CM, ICD-10-CM, CPT, Uniform Hospital
Discharge Data Set, Medicare Guidelines, and other appropriate
classification systems--- Demonstrates knowledge of anatomy and
physiology to interpret general medical classifications for coding
outpatient encounter or inpatient discharge data -Assigns Codes:---
Under general supervision/mentoring:--- Codes all diagnostic and
operative information from the medical record using ICD-9-CM,
ICD-10-CM, and CPT coding classification systems--- Selects the DRG
for each inpatient case--- Verifies and abstracts all medical data
from the record to complete a data abstract on hospital encounters.
Corrects data as appropriate--- Ensures that all data abstracted
and/or coded are consistent with the guidelines outlined by JCAHO,
OSHPD, Official Coding Guidelines for Coding and Reporting, and
regional and local policy and is aware of fraud and abuse issues---
Clarification of Medical Records Documentation:--- Under general
supervision/mentoring:--- Interacts with physicians to clarify and
accurately document patient diagnostic and procedural information
through a query process--- Enters patient information into the
computerized inpatient and outpatient medical record databases,
ensuring the accuracy and integrity of the medical record abstract
or encounter data prior to transmitting case--- Ensures timely
record availability by meeting coding and abstracting
productivity/quality standards established for HIM Coder II Trainee
--- --- Confidentiality/Security of Systems:--- Maintains and
complies with policies and procedures for confidentiality of all
patient records--- Demonstrates knowledge of security of systems by
not sharing computer logonBasic Qualifications:--- Successful
completion of an AHIMA accredited coding certification program for
Certified Coder Specialist.--- Obtain minimum score of 65% on a
Kaiser Permanente HIM II Coder New Hire Skills Assessment---
Keyboarding skills -Licenses and Certifications:--- Registered
Health Information Technician Certificate OR Certified Coding
Specialist OR Registered Health Information Administrator
CertificateJob Schedule: Job Category: Health Information
Management
Keywords: Kaiser, La Mesa , Health Information Coder Trainee, Healthcare , La Mesa, California
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