Patient Records Abstractor 4 Per Diem

About the position The Patient Records Abstractor 4 Per Diem position at the University of California Davis Health System is a critical role within the Patient Care Services Coding and Billing Unit. This unit is responsible for the meticulous data collection and submission of professional and hospital charges for services rendered by the Emergency Medicine department. The incumbent will work under the general direction of the HIM Inpatient Coding Supervisor, focusing on reviewing medical record documentation for all Emergency Department (ED) patient encounters. This involves identifying all billable services and addressing any discrepancies between coding and documentation with the physician or provider. The responsibilities of this role include collecting and analyzing medical documentation, assigning appropriate CPT evaluation/management and procedure codes, as well as ICD-10 diagnosis and APC general ledger codes to facilitate accurate billing for services provided. The abstractor will prepare and enter charges into the online charge entry systems, ensuring compliance with all relevant federal, state, and carrier-specific rules and regulations related to professional fee and technical services. This position is essential for maintaining the integrity of the billing process and ensuring that all services rendered are accurately captured and billed. The role requires a comprehensive understanding of medical diagnostic and procedural terminology, as well as a college-level understanding of disease processes, anatomy, and physiology. The abstractor must remain current with periodic updates of all coding manuals and guidelines in accordance with federal, state, and local regulations. Additionally, the position may require occasional overtime, and the incumbent must be flexible in adapting to changing guidelines and requirements. Responsibilities • Review medical record documentation for all ED patient encounters. , • Identify all billable services and discuss discrepancies with the physician/provider. , • Collect and analyze documentation for coding purposes. , • Assign appropriate CPT evaluation/management and procedure codes. , • Assign ICD-10 diagnosis and APC general ledger codes for billing. , • Prepare and enter charges into the online charge entry systems. , • Ensure compliance with federal, state, and carrier-specific regulations related to billing. , • Communicate technical and clinical information to various stakeholders. , • Remain current with updates to coding manuals and guidelines. Requirements • Must possess CCS, CCS-P, RHIT, CPC, or RHIA with current credential. , • Experience with ICD-10-CM, APC, and CPT classification systems. , • Ability to read handwritten and transcribed documents in medical records. , • Ability to follow detailed guidelines for assigning diagnosis and procedure codes. , • Comprehensive knowledge of medical diagnostic and procedural terminology. , • College-level understanding of disease processes, anatomy, and physiology. , • Knowledge of federal, state, and local regulations regarding patient care information. , • Understanding of third-party payer reimbursement requirements. , • Ability to communicate technical information to physicians and administrative personnel. , • Ability to apply data security and confidentiality policies. Nice-to-haves • Experience in acute care, ED, and ambulatory care settings. , • Familiarity with coding updates and changes in regulations.

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