Health Information Coder Trainee

Company: Kaiser
Location: La Mesa
Posted on: January 18, 2023

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