Coder III - Inpatient

Salary : $112,243.04 - $136,437.60 Annually
Location : San Jose Metropolitan Area, CA
Job Type: Full-Time
Job Number: 25-J04-A
Department: Santa Clara Valley Health Care - Valley Medical Center
Opening Date: 02/25/2025
Closing Date: 3/11/2025 11:59 PM Pacific
Bargaining Unit: 01

Description

Under direction, to perform the most complex medical-record coding and abstracting duties of the Coder series, requiring advanced medical-record coding knowledge and skills. Coder III-Inpatient incumbents primarily work with moderate to highly-complex inpatient records, but may also perform coding and abstracting of outpatient records.
The list established from this recruitment will be used for all vacancies throughout the Santa Clara County Health System. This may include full time, part time, and extra help positions. If you are interested in these opportunities please fill out the appropriate questions.

Required: All applicants are required to attach proof of a valid medical coding certificate.
Typical Tasks

• Reviews and analyzes a wide variety of primarily inpatient medical record information, such as diagnostic, operative, monitoring, and life-sustaining medical procedures for coding and abstracting purposes;
• Codes a wide variety of inpatient procedures and primary and secondary diagnoses according to the International Classification of Diseases (i.e., ICD-9-CM or subsequent adaptation, such as ICD-10-CM/ PCS), Current Procedural Terminology (CPT-4), and other coding systems applicable to Medi-Cal, Medicare, and other patient insurances;
• Assigns Medicare Severity Diagnostic Related Group (MSDRG) and Ambulatory Payment Classification (APC) numbers;
• Relies on a knowledge of anatomy, physiology, disease processes, and medical terminology in order to complete and properly sequence the coding of procedures and diagnoses, and to determine proper codes for diagnoses and procedures not clearly listed in the ICD and CPT codes;
• Organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements and hospital targets;
• Abstracts and prepares pertinent medical chart data--for statistical indexing, studies, approved Institutional Research Boards (IRB's) and preparation of summary reports to various agencies--in accordance with criteria established by the facility and/or the Office of Statewide Hospital Planning and Development (OSHPD) and/or including (but not limited to) other Federal and State regulatory bodies, and individual physicians;
• Enters appropriate patient information into the computerized inpatient and/or outpatient medical record databases;
• Proofreads computer input and output to ensure the correctness of entries and reviews rejected entries to identify and correct errors;
• Communicates in writing with (i.e. queries) medical staff regarding incomplete or missing medical record information;
• Acts as an expert resource person and may provide guidance and assistance to other coders;
• 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 this function are typically acquired through training and experience equivalent to graduation from a high school (or GED equivalent), certification by the American Health Information Management Association as a Certified Coding Specialist (CCS) plus one or more years of acute care hospital outpatient and inpatient hospital coding/abstracting experience within the last five (5) years. Work experience must have involved utilizing an encoder program for Medicare reimbursement coding, ICD-9 diagnosis and procedure coding, CPT coding, MS-DRG, and APR-DRG assignment.
Demonstrated competency in coding and abstracting medical records, in accordance with ICD-9-CM (or subsequent adaptation) and CPT-4 systems, or other applicable medical coding systems as required.

Knowledge of:

• Coder-related regulatory and data reporting agencies and their functions;
• Coding , abstracting, and terminology systems such as: International Classifications and Diseases 9-Clinically Modified (ICD 9-CM or subsequent adaptation) coding system; current CPT- 4 procedural coding system, Medial Severity Diagnosis Related Group (MSDRG) system, and abstracting systems;
• The abstract patient data fields, abstracting and coding techniques and statistical methods, and OSHPD reporting requirements;
• Comprehensive medical terminology covering a wide variety of medical specialties, including anatomy and physiology and the disease process;
• Components and format of the medical record, including but not limited to laboratory findings, special tests, medications, surgical procedures, therapy systems, surgery and other reports, history and progress notes, and consent documentation;
• The organization, services, and patient treatment interrelationships and sequences of a comprehensive teaching hospital;
• Health Information Management Services procedures;
• The complete revenue management cycle;
• English grammar, punctuation, and spelling and general English usage;
• Computerized patient data systems;
• Basic mathematics.

Ability to:

• Collect and analyze inpatient clinical information in order to accurately report codes and abstract relevant information used for processing reimbursement claims, research, statistical analysis, and other purposes such as clinical care improvement, financial planning, and marketing initiatives;
• Effectively use various computer systems in the performance of job functions;
• Read and comprehend the technical elements of a medical chart;
• Analyze, code, and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system;
• Consistently code complex patient medical records at established productivity rates and with an accuracy rate of 95% or above;
• Recognize missing elements, infer procedural and treatment relationships, and properly sequence information for coding and abstracting data from a medical record;
• Prepare clear and concise narrative, statistical, and graphic reports;
• Set work priorities and work independently, exercising considerable independent judgment;
• Communicate clearly both verbally and in writing with the public, patients, medical, nursing, technical staff, and legal counsel;
• Work effectively and harmoniously with others;
• Code and abstract inpatient records in accordance with agency-approved coding systems and national coding guidelines;
• Maintain an understanding of regulations, standards and practices as they relate to Health Information Management;
• Safely perform physical activities such as: reaching over ones head and bending down to retrieve files, standing, pulling records, and/or sitting for long periods of time, periodic lifting moderately heavy file containers (up to 50 pounds) and pushing heavy carts (may be required for some positions).

The County offers comprehensive first-class medical, dental, and vision benefits plans for County employees and their dependents, including plans with no deductibles, no co-pays, no co-insurance, and no prescription drug co-pays. Learn more

The County also offers generous paid time off with significant vacation, sick time, and 13 paid County holidays annually! Details are included in the with the bargaining unit applicable to the job classification.

In addition to the amazing perks above, the County also offers the additional benefits below.

Retirement Benefits
The County offers robust retirement plans including a (similar to the private sector's 401(k) plan) and the In addition to lifetime retirement income available through the CalPERS pension plan, the 457(b) Deferred Compensation plan provides a great way to save for retirement and supplement the defined benefit pension available to employees. These plans help our employees build a plan for their future and contribute to their family's long-term financial well-being.

Health Flexible Spending Account
The empowers employees to manage healthcare expenses efficiently with tax-free contributions (up to $3,200 for the 2024 calendar year). Secure tax-free solutions for your healthcare expenses and enjoy the flexibility to manage your healthcare finances effectively with the HFSA.

Dependent Care Assistance Program (DCAP)
The enables employees to utilize tax-free funds for dependent care services, facilitating a convenient and cost-effective approach for managing your dependent care expenses. The County also offers the , an employer-funded DCAP, for employees with annual income under $120,000.

Life and AD&D
The County offers life and disability benefits including , Insurance, These benefits ensure financial security and income support when you and your family need it most.

Employee Assistance Program (EAP)
The County prioritizes employee mental health and well-being and offers a top-tier through Concern providing confidential counseling sessions covering stress, anxiety, relationships, grief, as well as financial/legal services, personal coaching, child and elder care referrals, and comprehensive crisis support.

Employee Wellness
The offers free wellness programing, fitness classes and resources; including Elevate My Wellness an all-in-one platform designed to elevate your well-being journey.

Education Reimbursement
A generous program is available, including Education Reimbursement for employees seeking additional training and professional development.

NOTE: Benefit and Retirement information may vary from bargaining unit to bargaining unit. Due to changes in State Law, current pension provisions described in the union contracts are not automatically applied. Specific pension benefits for new hires who start on or after January 1, 2013 may be different than indicated in the union contracts.

Click here to access all Memoranda of Understanding and most recent Summary of Changes.
01

Please answer the following questions. Completion of the following supplemental questions is REQUIRED and is an integral part of the evaluation process. Initially, it will be used to determine minimum qualifications. For those applicants meeting the employment standards, this information will be critical in the subsequent competitive assessment to identify those candidates to be invited to continue in the examination process. Your responses to the questions may also be reviewed and scored in a Competitive Rating evaluation process based on pre-determined rating criteria. Your answers should be as complete as possible, as no additional information will be accepted from applicants once the Competitive Rating evaluation has begun. A response of "see resume" or "see application" will deem your application incomplete. Please include the name of employers, job titles, dates of employment, and hours worked per week for questions asking about work experience.
Do you understand the requirement to provide complete answers in order to determine relevant experience for each area in question?

• Yes
• No

02

Do you possess a high school diploma or equivalent?

• Yes
• No

03

Do you have certification by the American Health Information Management Association as a Certified Coding Specialist (CCS)?

• Yes
• No

04

Required:If you answered yes to the above question, please provide the certification number, date of issuance and expiration. If none, n/a.
05

REQUIRED:If you possess another medical coding certification by the American Health Information Management Association (AHIMA) or AAPC, please list your certification name, number, issue date and expiration date. If none, type n/a.
06

Do you have one or more years of acute care hospital outpatient and inpatient hospital coding/abstracting experience within the last five (5) years?

• Yes
• No

07

How many years of acute care outpatient hospital coding/abstracting experience do you possess?

• None
• Less than one year
• One to less than two years
• Two to less than three years
• Three to less than four years
• Four to less than five years
• Five to less than six years
• Six to less than seven years
• Seven to less than eight years
• Eight to less than nine years
• Nine to less than ten years
• Ten years or more

08

How many years of acute care inpatient hospital coding/abstracting experience do you possess?

• None
• Less than one year
• One to less than two years
• Two to less than three years
• Three to less than four years
• Four to less than five years
• Five to less than six years
• Six to less than seven years
• Seven to less than eight years
• Eight to less than nine years
• Nine to less than ten years
• Ten or more years

09

Describe in detail your acute care outpatient AND inpatient hospital coding/abstracting experience within the last five (5) years. Work experience must have involved utilizing an encoder program for Medicare reimbursement coding, ICD-10 diagnosis and procedure coding, CPT coding, MS-DRG, and APR-DRG assignment. Must provide the employer's name, the dates of employment, the number of hours worked per week, and duties performed.
10

How did you find out about this job?

• Contacted by County Recruiter
• Contacted by a Recruitment Firm
• County Employee Referral
• County of Santa Clara Career Website
• County of Santa Clara Job Interests Email Notification
• Facebook
• Instagram
• LinkedIn
• Indeed
• Virtual Job Fair
• In Person Job Fair
• In-Person Networking Professional Event
• Virtual Networking Event
• Community Event
• Glassdoor
• Governmentjobs.com
• Professional Association
• Search Engine (Google, Bing, online search, etc.)
• Hospital Website: SCVMC, O'Connor Hospital, St. Louise Regional Hospital Website
• Handshake
• Student Career Center
• County Text Message
• Other (Specify in the next question)

11

If you selected an event/fair or other in the question above, please specify. If not, type n/a.
Required Question