Patient Records Abstractor 4

The Patient Records Abstractor 4 (PRA) will code as part of the Clinical documentation Improvement Program and must be able to interpret clinical documentation into codable terms to improve risk of mortality and severity of illness. The PRA will also be responsible for identification of HACs, POA, Patient Safety Indicators and other healthcare quality initiatives as required. This data is used for medical research, hospital and professional fee reimbursement. This unit also assures that all records are analyzed for deficiencies as identified by JCAHO, CMS, Title 22 and the medical staff. All data abstraction and coding is performed using OSHPD, JCAHO, CMA, UHDDS, and Title 22 documentation guidelines. Coded information is abstracted from the medical records of patients to generate a clinical patient database for the facility. This assures the maintenance and accuracy of diagnostic and procedural statistics for the facility as well as optimum appropriate reimbursement from third party payors, by the timely coding of diagnoses and procedures using the required classification systems, ICD-9-CM, CPT-4, DRGs, and APCs.

The Medical Records Department is comprised of eight different units with a staffing of over 171 FTEs whose primary purpose is to serve the interests of the individual patient by facilitating medical care, treatment, research and teaching through availability of well documented, current medical record and clinical data base. The Coding Unit is composed of 14 coder/abstractors who extract medical and demographic information from each patient record and convert that information into data which can be electronically stored, manipulated and retrieved.

Apply By Date: November 16, at 11:59 PM

Minimum Qualifications: For full consideration, applicants are encouraged to upload their license, certification, and educational degree/diploma if required for the position

• High School diploma or equivalent
• American Health Information Management Association (AHIMA) Certified Coding Specialist - Physician-based (CCS-P) OR Certified Coding Specialist (CCS), OR American Association of Professional Coders (AAPC) Certified Professional Coder (CPC) Certification OR Certified Outpatient Coder (COC) Certification
• RHIT OR RHIA OR CCS, with 3 years of acute care, inpatient hospital coding experience
• Experience must include assignment of DRG, and APC
• Familiarity with OSHPD, UHDDS, CMS and JCAHO documentation requirements
• Experience with and knowledge of instructional notations and conventions of ICD-9-CM, DRG, APC and CPT classification systems; and ability to follow the detailed guidelines related to their use in assigning single, and sequencing multiple, diagnosis and procedure codes for appropriate reimbursements and data collection
• Ability to read handwritten and transcribed documents in the medical record, interpret information, and enter complete and accurate data into an on- line encoding system
• Comprehensive knowledge of medical diagnostic and procedure terminology required
• College level understanding of disease processes, anatomy and physiology necessary to assign accurate codes using the ICD-9-CM and CPT coding conventions
• Knowledge of Federal, State and local government regulations and requirements which pertain to patient care information and requirements for a complete medical record for deficiency chart analysis
• Knowledge of third-party payor reimbursement requirements and an understanding of multi-medical specialties, encounters, and procedures in acute care, E D and ambulatory care settings
• Ability to communicate technical and clinical information concerning patient care and classification systems at different levels, physicians, ancillary, and administrative personnel
• Ability to apply policies and procedures regarding data security and confidentiality to protect the inappropriate release of information
• Ability to exercise judgement with minimal supervision
• Ability to be flexible & follow many different guidelines that change annually
• Ability to assume responsibility for compilation of clinical data related to inpatient and outpatient encounters including diagnoses, procedures, physicians and services
• Remains current with periodic updates of all coding manuals and guidelines in accordance with Federal, State and local regulations
• Ability to manage time schedules, deadlines, multiple requests and priorities, and to maintain productivity

Key Responsibilities

• 90% - REVIEWS, ABSTRACTS AND CODES INPATIENT, OUTPATIENT, AND AMBULATORY SURGERY RECORDS TO ENSURE DATA QUALITY AND TO OPTIMIZE REIMBURSEMENT
• 5% - PROVIDE SUPORT TO THE CODING UNIT
• 5% - PARTICIPATES IN EDUCATIONAL EXPERIENCES CONCERNING CODING AND ABSTRACTING ISSUES.
  

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: $48.64 - $60.44
• Salary Frequency: Hourly
• Salary Grade: 112
• UC Job Title: PAT RCDS ABSTRACTOR 4
• Number of Positions: 1
• Appointment Type: Staff: Career
• Percentage of Time: 100% Full-time
• Shift Hours: Day shift (08 hours)
• Location: Remote Worksite (REMOTE)
• Union Representation: EX-Patient Care Technical
• Benefits Eligible: Yes
• Hybrid/Remote/Onsite: This position is 100% remote
• THIS IS NOT AN H-1B VISA OPPORTUNITY

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

• Ability to handle the stress and pressures of a job where there is noise from conversation and office machines
• Ability to read text for long period of time from a book, medical record and/or computer terminal

Special Requirements

• This is a critical position, as defined by UC policy and local procedures, and as such, employment is contingent upon successful completion of background check(s), including but not limited to criminal record history background check(s)
• 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

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