Coder II - Trauma Administrative Services Department

Coder II – Trauma Administrative Services Department

County of Santa Clara

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).

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).

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

For more information, please contact Dennis Lee at  or email dennis.leegov.org.

• 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 Medi Cal or other third-party payers when different than the industry standard by CMS;
• Applies knowledge of anatomy, physiology, disease processes, and medical terminology to accurately assign and sequence the procedural coding, diagnoses, or HCPC codes;
• Accurately assigns Medicare Severity Diagnosis Related Group (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, and assists in the orientation of new staff to the unit;
• Reviews and resolves charge errors and/or coding discrepancies;
• Follows department policy regarding notification of incomplete or missing information from the patient record;
• Communicates with other departments and providers regarding account clarification and corrections;
• Maintains HIPAA 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.

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:

• 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…