Health Information Coder 3

Responsibilities

• Retrieves and reviews comprehensive medical records and information from applicable systems to identify relevant clinical documentation and determine appropriate follow-up.
• Evaluates the complete episode of care for inpatient cases and assigns accurate ICD-10-CM and ICD-10-PCS codes based on clinical documentation, diagnoses, procedures, and applicable coding guidelines.
• Determines appropriate MS-DRG assignment based on the clinical data and coding of each inpatient case.
• Ensures coding and data abstraction meet applicable external regulatory, accreditation, quality, and payer requirements, including HCAI, HCFA, The Joint Commission, NCQA, and other applicable data submission requirements.
• Accurately enters codes and abstracts clinical and demographic data into applicable coding and database systems.
• Participates in coding audits, educational sessions, and quality improvement activities; provides feedback and training as requested.
• Consistently meets or exceeds departmental production standards established for the assigned DRG coding level.
• Consistently meets or exceeds departmental quality and accuracy standards established for the assigned DRG coding level.
• Maintains current knowledge of medical terminology, disease processes, anatomy and physiology, coding guidelines, and DRG methodologies.
• Reviews and follows up on physician documentation, including dictation and clinical notes, to clarify clinical information necessary for accurate coding and DRG assignment.
• Identifies and resolves coding and documentation discrepancies and escalates issues to the appropriate lead or manager when necessary.
• Reports coding, workflow, or other operational concerns to the appropriate lead or manager.
• Collaborates and communicates effectively with internal and external UCSF Health staff, providers, customers, and other stakeholders.
• Demonstrates an understanding of the DRG coding mission within UCSF Health, including the relationship between DRG coding, accounts receivable (AR), and data submission processes.
• Performs data searches and retrieves information from applicable systems to support coding, validation, and follow-up activities.