Role Description
Patient Record Abstractor fulfills a role as a Medical Coder for UCSF’s physician practices. They review patient records, discharge summaries, operative reports, and other clinical documentation to assign standardized codes for diagnoses, procedures, and services. They apply national and international coding classifications to ensure records reflect the care delivered, supporting accurate reimbursement and reliable clinical data.
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Knowledge of Current Procedural Terminology (CPT), Internal Classification Diseases, 10th edition, Clinical Modification (ICD-10-CM), and Healthcare Common Procedural Coding System (HCPCS).
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Operate within a healthcare records or billing team.
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Close liaison with clinicians, clinical coders, and administrative staff to resolve documentation queries.
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Maintain currency with coding updates, compliance requirements, and professional standards.
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Participate in regular audits to monitor coding quality.
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Timely processing of case volumes while maintaining high accuracy.
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Adherence to confidentiality and information governance standards.
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Contribution to process improvements that enhance data quality and coding efficiency.
Qualifications
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Minimum two years professional fee coding experience or equivalent experience/training.
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Strong communications skills, with the ability to interpret and convey complex clinical finance information in a clear, concise manner.
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Ability to prepare compelling and informative reports and presentations.
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Strong analytical and problem-solving skills, with the ability to evaluate the effectiveness of workflows and systems and propose innovative solutions.
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Strong interpersonal skills, with the ability to collaborate effectively on complex projects in a team environment with staff from a wide variety of business and clinical areas.
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Must be able to pass all classes related to the UCSF Medical Center’s computer systems as well as related UCSF coding and billing applications.
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Demonstrated intermediate knowledge of medical terminology, CPT, ICD-10 coding conventions, and clinical documentation requirements.
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Prior experience in healthcare related setting.
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Knowledge of Federal, State, and Commercial carrier’s coding and billing standards.
Requirements
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Required Licenses and/or Certifications:
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Certified Professional Coder (CPC)
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Certified Coding Specialist—Physician Based (CCS-P)
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Certified Coding Associate (CCA)
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Certified Coding Specialist (CCS)
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Registered Health Information Technician (RHIT)
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Registered Health Information Administrator (RHIA)
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Licensure equivalent to be evaluated by FPRMO management.
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Preferred Qualifications:
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Secondary coding certification such as Certified Interventional Radiology Coder (CIRC), Certified Emergency Department Coder (CEDC), etc.
Benefits
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New hire sign-on bonus of $2,000 for eligible candidates.
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Bonus payable after 30 days of continuous employment.