E&M/Specialty Coder
Job in
Stockton, San Joaquin County, California, 95211, USA
Listed on 2026-02-18
Listing for:
Kaiser Permanente
Full Time
position Listed on 2026-02-18
Job specializations:
-
Healthcare
Healthcare Administration, Medical Billing and Coding, Medical Records
Job Description & How to Apply Below
Under direct supervision, the E&M/Specialty Coder is responsible for accurate coding of professional services (diagnoses, conditions and procedures) from medical record documentation in a hospital setting. Working from appropriate documentation in the medical record, assigns codes and modifiers with ICD-CM, CPT and HCPCS Level II codes.
All work is performed in accordance with the rules, regulations and coding conventions of ICD-CM Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD-CM, CPT and HCPCS code book, CPT Assistant, NCCI Edits, OSHPD and Kaiser Permanentes organizational and institutional coding guidelines.
Essential Responsibilities:
+ Review Medical Records to identify diagnoses/procedures.
+ Under supervision, codes all diagnostic and operative information from the medical record using ICD-CM, CPT and HCPCS coding classification systems.
+ Verifies and abstracts all medical data from the record to assign appropriate codes for the following settings:
Inpatient Hospital (IP), Hospital Emergency (ED), Hospital observation (HOPS), Hospital Ambulatory (HAS) Hospital Outpatient (HOV) and Medical
+ Office.
+ E&M/Specialty Coder may require specialty coding and will remain part of the responsibilities as long as business dictates.
+ + Corrects data as appropriate.
+ + Review Medical Records to resolve Ingenix and Health Connect Coding Edits.
+ + Under supervision, identify and resolve coding related edits by reviewing the medical record and ensuring that all data and codes are consistent with ICD-CM Official Guidelines, CPT, CPT Assistant, CMS, OMFS, Medi Cal, USDOL, as well as KP Regional and Local policies.
+ Corrects data as appropriate.
+ + Work Organization and Prioritization.
+ + Under general supervision, organizes and prioritizes all work to ensure that records are coded, and edits are resolved, in a timeframe that will assure compliance with regulatory, billing and SOX requirements.
+ + Completeness of Medical Record Data.
+ + Under general supervision, interacts with clinical contracts to clarify and promote accurate documentation of patient diagnostic and procedural information.
+ Enters patient information into the computerized medical record and billing systems, ensuring the accuracy and integrity of the medical record data abstracted or encounter
+ data corrected, prior to submitting the data.
+ Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the E&M/Specialty Coder position in the current Coder Work At
+ Home agreement.
+ Provides feedback to monitor service provider and line of business compliance with regulatory requirements.
+ Confidentiality / Security of Systems Maintains and complies with policies and procedures for confidentiality of all patient records.
+ Demonstrates knowledge of security of systems and associated policies and procedures for maintaining the security of the data contained within the systems.
+ Other Duties:
Answers the telephone promptly and identifies themselves and the department.
+ Acts as a resource person to other departments regarding coding questions and issues.
+ Performs other duties as assigned.
Grade 594
Basic Qualifications:
Experience
+ Minimum two years, within the last three years, certified professional coding experience.
Education
+ High School Diploma or GED.
+ Completion of classes in medical terminology, anatomy, physiology, current ICD CM and CPT coding conventions, and disease process from an accredited program is required.
License, Certification, Registration
+ Certified Coding Specialist - Physician Based OR Certified Professional Coder OR Registered Health Information Technician
Additional Requirements:
+ Achieve a minimum score of 80% on the E&M/Specialty Coder test.
+ Basic knowledge of and use of computer keyboard
+ Must be able to meet production and quality standards established for the position.
+ Demonstrated knowledge of anatomy, physiology, medical terminology and disease processes.
+ Demonstrated ability to understand the clinical content of a health record.
+ Demonstrated ability to communicate with…
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