Medical Coder-Certified

• Completes detailed analysis of medical records for chart content and documentation requirements. 
• Assigns diagnostic codes and abstracts patient medical record information according to the International Classification of Diseases 9th Edition Systems (ICD-9-CM) and Current Procedure Terminology (CPT-4) 
• Manual and coding conventions and guidelines as established by state and federal reporting requirements. 
• Completes abstracting functions of inpatient, outpatient, and emergency records. Enters coded medical records data on computer terminal; selects diagnosis and operations codes from computer encoder and designated abstracting system. 
• Review medical records and verifies coding and Medicare Severity Diagnosis-Related Groups (MS-DRGs) assignments in response to billing requests. 
• Responds to authorized request from agencies, administration and individuals regarding coding and DRG questions. 
• Maintains a working knowledge of current guidelines and regulations affecting code assignments through continuing education sessions and approved references. 
• Assists physicians with correspondence for legal and insurance information. Keep records and prepares reports and correspondence as required. 
• May serve as a lead worker; may train staff.

Experience: One year of experience in an acute-care hospital or health care facility with experience in medical coding or medical records.

Certification: Possession of a current Certified Coding Specialist (CCS) certificate issued by the American Health Information Management Association or Certified Professional Coder (CPC) certificate issued by the American Academy of Professional Coders.

Substitution: Current registration as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) certificate may be substituted for the CCS or CPC certificate.

Medical terminology, anatomy and physiology, and study of disease processes; current knowledge of abstracting medical records according to ICD-9-CM classification systems and CPT-4 coding guidelines; standards and regulations pertaining to the maintenance of patient medical records; medical records coding systems; health information systems for computer application to medical records.

Review medical record information, correctly assign codes to diagnosis and procedures; utilize the ICD-9-CM and CPT-4 coding guidelines to code medical record entries; abstract information from medical records in accordance with defined regulations; read medical record notes and reports; assign accurate Medicare Severity Diagnostic Related Groups; operate computers, office equipment and related software; make independent decisions in procedural matters; establish and maintain effective working relationships with other employees, physicians, and the general public; communicate effectively, both orally and in writing.

Mobility-Frequent operation of a data entry device, repetitive motion, sitting and standing for long periods, walking; occasional pushing, pulling, bending, stooping, squatting, climbing; Lifting-Frequently 5 pounds or less; occasionally 5 to 30 pounds; Visual-Constant good overall vision and reading/close-up work; frequent color perception and use of eye/hand coordination; occasional use of depth perception and peripheral vision; Hearing/Talking-Frequent hearing of normal speech, hearing/talking on the telephone, talking in person; Emotional/Psychological-Decision making; concentration; occasional exposure to trauma, grief and death; Special Requirements-Some assignments may require working weekends, nights, and/or occasional overtime; Environmental-Occasional exposure to varied weather conditions.

Employees hired into this classification are members of a bargaining unit which is represented by SEIU Local 1021. 

Health Insurance:  San Joaquin County provides employees with a choice of three health plans:  a Kaiser Plan, a Select Plan, and a Premier Plan.  Employees pay a portion of the cost of the premium. Dependent coverage is also available. 

Dental Insurance:  The County provides employees with a choice of two dental plans:  Delta Dental and United Health Care-Select Managed Care Direct Compensation Plan.  There is no cost for employee only coverage in either plan; dependent coverage is available at the employee’s expense.

Vision Insurance:  The County provides vision coverage through Vision Service Plan (VSP).  There is no cost for employee only coverage; dependent coverage is available at the employee’s expense.

For more detailed information on the County’s benefits program, visit our website at www.sjgov.org under Human Resources/Employee Benefits. 

Life Insurance:  The County provides eligible employees with life insurance coverage as follows: 

 1 but less than 3 years of continuous service:                   $1,000
 3 but less than 5 years of continuous service:                   $3,000
 5 but less than 10 years of continuous service:                 $5,000
10 years of continuous service or more:                           $10,000 

Employee may purchase additional term life insurance at the group rate.

125 Flexible Benefits Plan:  This is a voluntary program that allows employees to use pre-tax dollars to pay for health-related expenses that are not paid by a medical, dental or vision plan (Health Flexible Spending Account $2550 annual limit with a $500 carry over); and dependent care costs (Dependent Care Assistance Plan $5000 annual limit). 

Retirement Plan:  Employees of the County are covered by the County Retirement Law of 1937.  Please visit the San Joaquin County Employees’ Retirement Association (SJCERA) at www.sjcera.org for more information.  NOTE:  If you are receiving a retirement allowance from another California county covered by the County Employees’ Retirement Act of 1937 or from any governmental agency covered by the California Public Employees’ Retirement System (PERS), you are advised to contact the Retirement Officer of the Retirement Plan from which you retired to determine what effect employment in San Joaquin County would have on your retirement allowance.

Deferred Compensation:  The County maintains a deferred compensation plan under Section 457 of the IRS code. You may annually contribute $22,500 or 100% of your includible compensation, whichever is less.  Individuals age 50 or older may contribute to their plan, up to $30,000. The Roth IRA (after tax) is also now available.

Vacation:  Maximum earned vacation is 10 days each year up to 3 years; 15 days after 3 years; 20 days after 10 years; and 23 days after 20 years.

Holidays:  Effective July 1, 2017, all civil service status employees earn 14 paid holidays each year.  Please see the appopriate MOU for details regarding holidays, accruals, use, and cashability of accrued time.

Sick Leave:  12 working days of sick leave annually with unlimited accumulation.  Sick leave incentive:  An employee is eligible to receive eight hours administrative leave if the leave balance equals at least one- half of the cumulative amount that the employee is eligible to accrue.  The employee must also be on payroll during the entire calendar year.

Bereavement Leave:  3 days of paid leave for the death of qualifying family member, 2 additional days of accrued leave for death of employee’s spouse, domestic partner, parent or child.

Merit Salary Increase:  New employees will receive the starting salary, which is the first step of the salary range.  After employees serve 52 weeks (2080 hours) on each step of the range, they are eligible for a merit increase to the next step.

Job Sharing:  Employees may agree to job-share a position, subject to approval by a Department Head and the Director of Human Resources.

Educational Reimbursement Program:  Eligible employees may be reimbursed for career-related course work up to a maximum of $850 per fiscal year.  Eligible employees enrolled in an approved four (4) year College or University academic program may be reimbursed up to $800 per semester for a maximum of $1600 per fiscal year.

Parking Supplemental Downtown Stockton:  The County contributes up to $20 per pay period for employees who pay for parking and are assigned to work in the Downtown Core Area.

School Activities:  Employees may take up to 40 hours per year, but not more than eight (8) hours per month, to participate in their children’s school activities.