Health Information Coder 3 (1 of 4) (Sign on Bonus eligible)

*** New Hires are eligible for a Sign-On Bonus *** The Health Information Coder III is a senior-level inpatient coder with an advance 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. ***Note: We are offering a new hire sign-on bonus of $2,000. All external new hires who have not worked for a UC in the last 12 months are eligible. The bonus is payable after 30 days of continuous employment. 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.

% of time Essential Function (Yes/No ) Key Responsibilities (To be completed by Supervisor) 100 Yes Retrieve and analyze comprehensive medical records and information systems for appropriate documentation and follow-up as appropriate. Evaluate full episode of care of clinical data for inpatient cases and assign appropriate codes using ICD-10-CM andICD-10-PCS classification systems. Includes assessment of the condition and diagnosis to conclude the coding of clinical data and DRG assignment. Meet external requirements for HCAI, HCFA, The Joint Commission, NCQA and payor data requirements. Accurately input codes and abstract data into current coding databases. Participate in coding audits and coding educational sessions and provide feedback and training. Meet or exceed department production standards for the DRG coding level. Meet or exceed department quality standards for the DRG coding level. Maintain knowledge of current medical terminology, disease processes, anatomy & physiology, and current DRG coding guidelines. Follow-up and clarify physician documentation (dictation and clinical notes). Report to a lead or manager. Interact with internal and external UCSF Health staff and customers. Satisfactory time and attendance 100% (To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)

REQUIRED QUALIFICATIONS High school graduation. Certified Coding Specialist (CCS) or Certified Inpatient Coder (CIC), or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification 3+ years’ experience inpatient DRG coding and abstracting. 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. 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. REQUIRED CERTIFICATIONS Certified Coding Specialist (CCS) or Certified Inpatient Coder (CIC), or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification PREFERRED QUALIFICATIONS Knowledge of HIMS database systems. Knowledge of HIMS procedures.