Patient Records Abstractor 4 Per Diem

#CA-SS

Under the general direction of the Supervisor, incumbent performs abstracting of medical services provided by UCDHS and affiliates. Incumbent identifies all billable services (IP Professional, Outpatient professional and facility, Hospital Service Departments, Freestanding, and Ancillary Services), CPT-4, ICD-10, and HCPCS codes for billing purposes to government agencies, insurance companies and patients. Incumbent is responsible for the accuracy of above procedure and diagnosis coding relative to corresponding documentation and standards. Incumbent will ensure compliance to all federal, state and carrier specific rules, regulations and requirements related to professional fee services are adhered to.

Apply By Date March 17, 2025 at 11:59PM

Minimum Qualifications - For full consideration, applicants are encouraged to upload license and/or certification if required of the position

• American Health Information Management Association (AHIMA) Certified Coding Specialist-Physician-based (CCS-P) or Certified Coding Specialist (CSS), or American Association of Professional Coders (AAPC) Certified Professional Coder (CPC) Certification
• No minimum education required
• Working knowledge and experience abstracting and coding using ICD-10 and CPT-4 codes.
• Comprehensive knowledge of medical diagnostic and procedure terminology.
• Knowledge of disease processes, anatomy and physiology necessary for assigning accurate codes.
• Ability to follow ICD-10 and CPT guidelines in assigning codes to visits and procedures.
• Ability to follow CMS and UCDHS teaching physician guidelines in applying evaluation and management codes.
• Knowledge of Federal, State and local government regulations and requirements, which pertain to patient care information.
• Knowledge of third party payor reimbursement requirements and reimbursement methodologies.
• Ability to interpret and communicate professional fee coding information to physicians and other UCDHS staff.
• Ability to manage time schedules, deadlines, multiple requests, priorities and maintain productivity.
• Excellent written and oral communication skills.
• Problem solving and decision making skills to independently define a problem, identify the resources available, create viable solutions and to take the necessary action.
• Organizational skills to maintain work area and in progress/pending work /patient lists, in such a way that the information is easily retrievable.
• Abides by the American Health Information Managements Association's established code of ethical principles to safeguard the public and contribute within the scope of the profession to quality and efficiency in health care, thus promoting ethical conduct.
• Abides by all compliance principles regarding fraud and abuse in the reimbursement environment.

Key Responsibilities

• 45% - Analyze Records and Documents to Determine Nature of Professional Services Rendered
• 45% - Assign Appropriate CPT, EM, Diagnosis, HCPCS and Modifiers
• 10% - Physician Feedback

Department Overview

The Health Information Management (HIM) Department is a critical part of the healthcare organization, dedicated to improving patient care, supporting research, and facilitating education through the efficient management of medical records and clinical databases. The department, which consists of over 200 Full-Time Equivalents (FTEs) across diverse units, is responsible for ensuring the accuracy, accessibility, and compliance of patient information, which is crucial for clinical decision-making, billing accuracy, and regulatory adherence.

The department includes key groups such as Inpatient and Outpatient Clinical Documentation Integrity (IP/OP CDI), All Coding Operations, the CDI Coding Quality Analyst Group, the HIM Clinical Analyst Team, and the Provider Advocate Team. Each of these teams plays a specialized role in supporting the organization's health information needs.

IP/OP CDI focuses on ensuring that clinical documentation accurately reflects the complexity and severity of patient care, contributing to appropriate coding, billing, and reimbursement. All of Coding Operations ensures that all patient records are coded accurately according to industry standards and regulatory requirements, supporting billing processes and ensuring compliance. The CDI Coding Quality Analyst Group is responsible for monitoring and improving the quality of clinical documentation and coding processes to ensure accuracy and efficiency. The HIM Clinical Analyst Team focuses on the analysis and optimization of clinical data systems, ensuring that health information is easily accessible and accurate across the organization in collaboration with other department data analysts. The Provider Advocate Team collaborates directly with physicians and other clinical staff to ensure accurate documentation and smooth integration of clinical data into patient records.

Together, these teams ensure that the department not only supports day-to-day clinical operations but also plays a key role in broader strategic initiatives. The HIM Department ensures that data integrity is maintained, healthcare regulations are followed, and operational workflows are optimized to support patient care and organizational efficiency. Through this multidisciplinary approach, the HIM Department significantly contributes to the organization's mission of delivering high-quality healthcare.

POSITION INFORMATION

• Salary or Pay Range: $56.21
• Salary Frequency: Hourly
• Salary Grade: 110
• UC Job Title: PAT RCDS ABSTRACTOR 4 PD
• UC Job Code: 004714
• Number of Positions: 1
• Appointment Type: Staff: Per Diem
• Percentage of Time: 20%
• Shift (Work Schedule): Days
• Location: Remote Worksite (REMOTE)
• Union Representation: EX-Patient Care Technical
• Benefits Eligible: No
• This position is 100% remote

Benefits

Outstanding benefits and perks are among the many rewards of working for the University of California. UC Davis offers a full range of benefits, resources and programs to help you bring your best self to work, as well as to help you and your family achieve your health, wellness, financial and career goals. Learn more about the benefits below and eligibility rules by visiting either our handy Benefits Summary for UC Davis Health Employees or Benefits Summary for UC Davis Employees and our Benefits Page.

If you are represented by a union, benefits are negotiated between the University of California (UC) and your union and finalized in a contract. Read your bargaining unit's employment contract, stay abreast of current negotiations and learn about collective bargaining at UC: https://ucnet.universityofcalifornia.edu/labor/bargaining-units/index.html

* High quality and low-cost medical plans to choose from to fit your family's needs
* UC pays for Dental and Vision insurance premiums for you and your family
* Extensive leave benefits including Pregnancy and Parental Leave, Family & Medical Leave
* Paid Holidays annually as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
* Paid Time Off/Vacation/Sick Time as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
* Continuing Education (CE) allowance and Education Reimbursement Program as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
* Access to free professional development courses and learning opportunities for personal and professional growth
* WorkLife and Wellness programs and resources
* On-site Employee Assistance Program including access to free mental health services
* Supplemental insurance offered including additional life, short/long term disability, pet insurance and legal coverage
* Public Service Loan Forgiveness (PSFL) Qualified Employer & Student Loan Repayment Assistance Program for qualified roles
* Retirement benefit options for eligible roles including Pension and other Retirement Saving Plans. More information on our retirement benefits can be found here
* UC Davis cares about building a community, which is why we provide resources to enhance diversity, equity and inclusion as well as Employee Resource Groups (ERGs) to support our staff

Physical Demands

• Standing - Occasional Up to 3 Hours
• Walking - Occasional Up to 3 Hours
• Sitting - Frequent 3 to 6 Hours
• Lifting/Carrying 0-25 Lbs - Occasional Up to 3 Hours
• Pushing/Pulling 0-25 Lbs - Occasional Up to 3 Hours
• Bending/Stooping - Occasional Up to 3 Hours
• Squatting/Kneeling - Occasional Up to 3 Hours
• Twisting - Occasional Up to 3 Hours
• Reaching overhead - Occasional Up to 3 Hours
• Keyboard use/repetitive motion - Frequent 3 to 6 Hours

Mental Demands

• Sustained attention and concentration - Frequent 3 to 6 Hours
• Complex problem solving/reasoning - Occasional Up to 3 Hours
• Ability to organize & prioritize - Frequent 3 to 6 Hours
• Communication skills - Frequent 3 to 6 Hours
• Numerical skills - Occasional Up to 3 Hours
• Constant Interaction - Frequent 3 to 6 Hours
• Customer/Patient Contact - Frequent 3 to 6 Hours
• Multiple Concurrent Tasks - Frequent 3 to 6 Hours

Work Environment

UC Davis is a smoke and tobacco free campus effective January 1, 2014. Smoking, the use of smokeless tobacco products, and the use of unregulated nicotine products (e-cigarettes) will be strictly prohibited on any UC Davis owned or leased property, indoors and outdoors, including parking lots and residential space.

Special Requirements - Please contact your recruiter with questions regarding which activities apply by position

• This is a critical position, as defined by UC Policy and local procedures, and as such, employment is contingent upon clearing a criminal background check(s) and may include drug screening, medical evaluation clearance and functional capacity assessment
• This position is designated as a mandated reporter under CANRA and UC policy, and employment is contingent on compliance with applicable policies, procedures and training requirements

Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.

Diversity, Equity, Inclusion and Belonging

At UC Davis, we're solving life's most urgent challenges to bring a fuller, healthier, and more resilient world within reach. We grow from every challenge we take on and we don't just maintain - we improve. We recognize that creating an inclusive and intellectually vibrant organization means understanding and valuing both our individual differences and our common ground. The most comprehensive solutions come from the most diverse minds and you belong here. As you consider joining UC Davis, please explore our Principles of Community, our Clinical Strategic Plan and strategic vision for research and education, and our latest efforts to outgrow the expected. The University of California, Davis is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age or protected veteran status.

For the University of California's Affirmative Action Policy, please visit: https://policy.ucop.edu/doc/4010393/PPSM-20

For the University of California's Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

Because we want you to be seen, our recruiting process at UC Davis fosters authenticity, diversity, and inclusion. Studies have shown that some people may not apply to jobs unless they meet every single qualification. Each unique role at UC Davis has a set of requirements and you could be perfect for this role, or you could be perfect for the next role! Don't meet all the requirements? We still encourage you to apply! #YouBelongHere

To learn more about our background check program, please visit: https://hr.ucdavis.edu/departments/recruitment/ucd/selection/background-checks