[Hiring] Patient Records Abstractor II @University of California San Diego

Role Description

UC San Diego Health's Revenue Cycle department supports the organization's mission to deliver outstanding patient care and to create a healthier world - one life at a time. We are a diverse, patient-focused, high-performing team with a commitment to quality, collaboration, and continuous improvement that enables us to deliver the maximum standard of care to our patients. We offer challenging career opportunities in a fast-paced and innovative environment and we embrace individuals who demonstrate a deep passion for problem-solving and customer service.

The Patient Abstractor reviews and analyzes medical records to identify documentation deficiencies and ensure compliance with:

• The Joint Commission (TJC) standards
• Title 22 regulations
• Medical Staff Bylaws
• Rules and Regulations
• Health Information Management (HIM) policies and procedures

This role serves as a primary liaison between:

• Deficiency analysis staff
• Management
• Clinical providers
• Other key stakeholders

The Patient Abstractor:

• Assigns required documentation and dictation deficiencies
• Monitors record completion through the electronic health record (EHR) and legacy systems
• Tracks outstanding deficiencies to ensure responsible providers meet record completion requirements within established timeframes
• Supports physician billing and coding functions by assisting with the accurate assignment of billing-related documentation
• Ensures the appropriate routing of deficiency notifications and communications to providers and their respective departments
• Acts as a key point of contact between HIM, clinical staff, and coding teams
• Helps resolve documentation and workflow-related issues while supporting effective communication across departments
• Troubleshoots electronic and technical issues related to electronic signature systems
• Coordinates resolution efforts with the appropriate technical and operational teams

Success in this position requires:

• Strong verbal and written communication skills
• The ability to build collaborative relationships
• The capacity to clearly explain complex documentation, compliance, and workflow requirements to diverse audiences

The Patient Abstractor may also provide support for other HIM functions, including:

• Maintenance of the Master Patient Index (MPI)
• Scanning and indexing of patient records
• Document imaging workflows
• Release of Information (ROI) processes

Qualifications

• Graduation from High School or a GED with a demonstrated knowledge of the applicable medical terminology
• Successful completion of AHIMA or AAPC accredited Health Information Tech/Management or Coding Program
• Certified Professional Coder (CPC-A) or credentialed by AHIMA (RHIT)
• Experience coding physician, outpatient, inpatient, ancillary or surgical claims
• Prior experience working in a hospital/physician office environment

Requirements

• Two (2) years of related hospital clerical experience; one of which must be in the type of work to be performed; or an equivalent combination of education and experience
• Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification
• Professional fee coding certification, such as CPC or CCS-P
• Healthcare Environment Experience
• Experience in Release of Information of medical records
• Familiar with HIPAA and CMS Medicare Guidelines
• Familiar with TJC (Joint Commission) and Title 22 Regulations
• Experience with chart analysis in Epic
• Experience working with transcription vendors
• Experience working with Patient Identity/Data Integrity

Special Conditions

• Must be able to work various hours and locations based on business needs
• Employment is subject to a criminal background check and pre-employment physical