Coder II Trauma Administrative Services Department

San Jose, CA - USA

Yearly Salary: $ 96493 - 117332

Posted on: 30+ days ago

Vacancies: 1 Vacancy

Job Summary

Description

Coder II incumbents work under general supervision performing moderately complex coding and abstracting of assigned tasks including but not limited to outpatient inpatient and specialized medical service records. For training purposes Coder II incumbents may be assigned moderately complex inpatient records. All coding work must be performed in accordance with applicable Federal and State coding guidelines and the coding policies and procedures of the Santa Clara Valley Health and Hospital System (SCVHHS).

* * * * * * * * * * * * IMPORTANT * * * * * * * * * * *

The preferred candidate will possess knowledge of trauma data management principles and methods including experience with trauma registry practices and data analysis in a trauma center setting. The incumbent must hold and maintain a current applicable coding certification.

The position requires possession of a Certified Abbreviated Injury Scale Specialist (CAISS) certification.This certification will be in lieu of the following certifications: Certified Coding Associate (CCA) Certified Medical Coder (CMC-PMI) Certified Medical Coder (CCS) Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) or Certified Professional Coder (CPC-AAPC).

We are currently recruiting for one (1) full-time Coder II position within the Trauma Administrative Services Department at the Regional Medical Center.

Position: One (1); FTE 1.0
Shift: Varies

For more information please contact Dennis Lee at or email.

The Power of WE: Together we can make a

greater impact. Bringing better care and expanding healthcare services across

the community. Santa Clara Valley Healthcare (SCVH) is the second-largest

public healthcare system in California comprising three acute-care hospitals 14 clinics and more than 60 specialty and subspecialty services. Our mission is to

deliver high-quality accessible healthcare and exceptional service to all

residents of Santa Clara County.

Santa

Clara Valley Medical Center- SCVMC

is a full-service tertiary acute-care teaching hospital with 699 licensed beds

providing a wide range of specialized services including Rehabilitation Burn

Trauma and NICU. SCVMC was ranked by U.S. News and World Report as the #6

Rehabilitation Hospital in the nation and #1 in the West and was designated as a

2024 High-Performing hospital for Maternity Care Heart Failure Stroke Hip

Fracture and Pneumonia.

OConnor

Hospital- OConnor Hospital (OCH)

is a 358-licensed bed acute care facility offering a full range of inpatient

and outpatient medical surgical and specialty programs to residents of Santa

Clara County. It was founded in 1889 as one of the first hospitals in the

county. OCH has experienced significant growth over the past five years both

in its inpatient volume and Emergency Department visits. Along with these

volume increases ancillary and clinical departments such as imaging lab pharmacy and respiratory care have also grown.

Regional Medical Center -Regional Medical Center (RMC) is a 258-bed hospital serving as the primary emergency healthcare provider for East San Jose treating a wide range of critical and life-threatening conditions for over 60 years. Since the SCVH integration of RMC effective April 1 2025 RMC has expanded its critical services including Level II trauma care a Thrombectomy-capable Stroke Center and STEM care and has seen increases in emergency visits and inpatient volume.

St. Louise Regional

Hospital- Since

1989 St. Louise Regional Hospital (SLRH) has served residents of

Santa Clara and San Benito Counties offering a comprehensive range of

inpatient and outpatient medical specialties. SLRH has 93 beds is a Designated

Primary Stroke Center and is the only acute care hospital in the area. Located

in Gilroy SLRH maintains a CALSTAR 2 emergency helicopter base on the

premises.

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Typical Tasks

(The following list includes examples of tasks that may be assigned to a Coder II position depending on the area of assignment. No single position will be assigned all tasks listed; nor is the list exhaustive.)

Reviews abstracts and codes medical-record data using coding systems such as ICD-9-CM CPT-4 and HCPCS or subsequent adaptations;
May perform coding review or audit of provider charges submitted electronically charge ticket or electronic file;
Provides CPT and ICD-9 codes to unit and other staff when required;
Records the coding information into the appropriate charge system such as a computer system paper-charge ticket and/or electronic file;
Reviews and abstracts procedural diagnostic services and/or facility level of services from the medical record and assigns the appropriate coding;
Identifies and assigns diagnosis CPT procedural codes HCPC codes or facility level of service utilizing the current adaptation of the International Classification of Diseases (ICD-9-4) CPT-4 HCPC or LOS;
May assign unique coding required by MediCal or other third-party payers when different than the industry standard by CMS;
Applies knowledge of anatomy physiology disease processes and medical terminologyto accurately assign and sequence the procedural coding diagnoses or HCPC codes;
Accurately assigns Medicare Severity Diagnosis RelatedGroup (MSDRG) and Ambulatory Payment Classification (APC) number or other coding classifications;
(In Diagnostic Imaging Unit) Reviews various radiology reports for appropriate CPT codes and assigns codes accordingly using ICD-9 code set or subsequent adaptation (such as ICD-10)and performs other coding-related duties pertaining to diagnostic imaging;
Participates in the development of policies and procedures; supports the implementation of departmental policies and procedures;
Reviews Coder I work for completeness and correctness andassists in the orientation ofnew staff to the unit;
Reviews and resolves charge errors and/or coding discrepancies;
Follows department policy regarding notification ofincomplete or missing information from the patient record;
Communicate with other departments and providers regarding account clarification and corrections;
Maintains HIPPA confidentiality privacy and security of all patient-related information;
Maintains harmonious work relationships;
May be assigned as a Disaster Service Worker as required;
Performs other related work as required.

Employment Standards

Sufficient education training and experience to demonstrate the ability to perform the above tasks and possession of the following qualifications including the knowledge and abilities indicated below:

Training and Experience Note: The knowledge and abilities required to perform these functions are normally acquired through possession of a high school diploma (or GED equivalent) possession of a CCA CMC (PMI) or CCS or RHIT or RHIA or CPC (AAPC) certification and two (2) years experience as a medical coder which included coding outpatient and/or inpatient records using ICD-9 diagnosis (or subsequent ICD adaptation) procedures CPT codes HCPS coding system;

Note:Specific certifications such as Radiology Certified Coder (RCC)--in lieu of above listed certifications--may be required if specific job duties are such that a particular coding credential is more specific Coder functions and certifications may vary certifications will be evaluated on a case-by-case basis in order to assess applicability to the Coder II duties assigned as well as the required knowledge and abilities.

Coders are required to maintain their coding competency regarding procedural diagnosis HCPC codes and LOS facility charges a strong understanding of coding compliance and regulatory payer guidelines and other guidelines related to coding of medical must complete the required Continuing Education Units (CEUs) annually to ensure their respective certifications remain active and in good standing.

Knowledge of:

Coding guidelines abstracting and medical terminology to utilize and assign appropriate coding: current ICD-9-CM and CPT-4 HCPCs or subsequent adaptations;
Computer encoding software programs online tools coding references and websites;
The principles and practice of accurate and compliant abstracting and coding techniques;
Comprehensive medical terminology anatomy and physiology and disease processes related to medical specialties;
Components and format of the hard copy and/or electronic version of medical record including but not limited to laboratory findings special tests medications surgical procedures therapy services surgical events other dictated or hand written process notes and reports consents etc;
English grammar punctuation spelling and general English usage;
Computerized patient data systems.

Ability to:

Read and comprehend the elements of a medical chart medical-record notes and reports;
Analyze code and abstract moderately-complex technical data from medical records covering a wide variety of ancillary/outpatient--and in some cases inpatient--services;
Identify missing elements inferred between procedural and treatment relationships;
Properly sequence abstracted/coding information from a medical record;
Read and understand medical record notes and reports and accurately classify all diagnoses and procedures;
Effectively use the various computer systems necessary to perform job functions;
Communicate clearly both orally and in writing with medical and nursing staffemployees at all levels of the organization patients and the public;
Plan organize and prioritize work and meet deadlines;
Reason logically and use sound judgment in the performance of duties.

Required Experience:

DescriptionCoder II incumbents work under general supervision performing moderately complex coding and abstracting of assigned tasks including but not limited to outpatient inpatient and specialized medical service records. For training purposes Coder II incumbents may be assigned moderately complex...