Health Information Coder Trainee

Company: Kaiser
Location: Encinitas
Posted on: January 27, 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 logon

Basic 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 Certificate

Job Schedule:
Job Category: Health Information Management

Keywords: Kaiser, Encinitas , Health Information Coder Trainee, Healthcare , Encinitas, California