Under direct supervision, the Inpatient Coder is responsible for accurate coding and abstracting of inpatient and related hospital cases from medical record documentation. The role assigns diagnosis, procedure, and modifier codes using ICD-CM, ICD-PCS, CPT, HCPCS, and other specialty systems as required.
The position also supports coding and abstracting for Observation (OBS), Hospital Ambulatory Surgery (HAS), Emergency Department (ED), and complex Hospital Outpatient Visit (CHOY) services when needed. Work must comply with applicable coding rules, regulations, and guidelines, including ICD-CM Official Guidelines for Coding and Reporting, Coding Clinic, CMS guidance, OSHPD requirements, and Kaiser Permanente coding standards.
Responsibilities include reviewing medical record documentation, sequencing diagnoses and procedures, determining DRG accuracy, abstracting data for submission and reporting, correcting data when needed, collaborating with physicians for clarification, and maintaining confidentiality and security of patient information. The role must also meet productivity and quality standards for coding and abstraction.
- Three years of continuous hospital coding experience within the last five years
- High school diploma or GED
- Completion of coursework in medical terminology, anatomy, physiology, current ICD-CM, ICD-PCS, and CPT coding conventions, and disease process from an accredited program
- Certified Coding Specialist, Registered Health Information Technician, or Registered Health Information Administrator credential
- Ability to use a computer keyboard and mouse
- Minimum score of 75% on the KP Inpatient Coding test
- Ability to meet productivity and quality standards
- Strong understanding of anatomy, physiology, medical terminology, and disease processes
- Knowledge of coding quality, coding compliance, reimbursement methodologies, and current coding classification rules
- Ability to communicate with physicians regarding diagnosis and procedure clarification
- Must maintain coding credentials and complete required continuing education units
- Must abide by AHIMA and AAPC codes of ethics
- Must be willing to work in a Labor Management Partnership environment
- Must reside in Northern California and align with Kaiser Permanente's Authorized States policy
Location
Oakland, California, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
1 month ago