Lead Coder

Under indirect supervision, the Lead Coder is regularly assigned to lead, train, coordinate, and review the work of assigned coders and/or others who need assistance, advice, instruction, training, and in-service education in coding and abstracting. In addition, the Lead Coder is also expected to code inpatient and all categories of outpatient services, diagnoses, procedures, and conditions working from appropriate documentation in the medical record when assigned or needed, using the appropriate coding classification system. Classification systems include ICD-CM (PCS, CPI*), HCPCS, as well as other specialty systems as required by diagnostic and procedural guidelines.All work must be performed in accordance with the rules, regulations, and coding conventions of the current ICD-CM/PCS official guidelines for coding and reporting Coding Clinic published by the American Hospital Association, the current ICD-CM/PCS code book, CPT, CPT Assistant, CMS, NCCI edits, OSHPD, and Kaiser Permanente's organizational institutional Coding Guidelines.Responsibilities:Review Medical Records to identify diagnoses/procedures.Organize and prioritize all work to ensure that records are coded in timeframes that assure compliance with regulatory requirements.Demonstrate an in-depth knowledge of diagnosis and procedure coding, including sequencing of codes and present on admission assignment in conformance with ICD-CM/PCS, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines, and other appropriate classification systems.Demonstrate knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data including the most complicated, involved encounters/cases.Code accurately and completely all diagnostic and operative information and professional hospital E/M services from the medical record using ICD-CM/PCS, CPT, and HCPCS coding classification systems.Accurately select the DRG for each inpatient case and review DRG discrepancies to ensure the appropriate DRG assignment.Verify and abstract all required data elements from the record as required for billing and data reporting.Ensure that all data abstracted is consistent with guidelines outlined by TJC, OSHPD, and CMS, regional and local policy.Serve as an expert resource for the coders and others with coding questions and inquiries.Support and mentor the coders and provide coder training as necessary.Perform ongoing review of selected inpatient and outpatient cases to ensure correct assignment and sequencing of codes.Participate in quality improvement peer review for coding, abstracting, and DRG/APC assignments performed within the Coding Department.Identify departmental performance/quality improvement opportunities.Conduct training and in-service education for assigned staff and serve as an expert on ICD/CPT/HCPCS and DRG/APC assignments, issues, and projects.Interact with physicians to clarify and accurately document patient diagnostic and procedural information.Ensure the accuracy and integrity of coded and abstracted data prior to coding completion and submission.Ensure timely record availability by meeting established coding, abstracting, and peer review productivity and quality standards specific to Coder Ills.Participate in medical record documentation review to monitor physician compliance with regulatory requirements.Maintain and comply with policies and procedures for confidentiality of all patient records.Act as a resource person to other hospital departments regarding coding questions and issues.Perform other duties as assigned by supervisors.Basic Qualifications:Must have at least five (5) years of continuous inpatient hospital coding experience within the last seven (7) years.High School Diploma/GED.Demonstrated completion of classes in medical terminology, anatomy, physiology, current ICD-CM and CPT coding conventions, and disease process from an accredited program.Registered Health Information Administrator OR Certified Coding Specialist OR Registered Health Information Technician.Additional Requirements:Demonstrated ability to understand the clinical content of a health record including complex cases and translate to coding.Must be able to communicate with physicians to clarify documentation of diagnoses/procedures.Ability to demonstrate knowledge of and utilize reviewing skills related to coding quality and compliance.Demonstrated ability to utilize principles and techniques of health record/data quality assurance and abstracting.Achieve a minimum score of 85% on the Kaiser Permanente HIM Coder II test Coding Editor test.Must maintain current AHIMA credential and complete all required Continuing Education (CE) units/hours.Must abide by the AHIMA and/or AAPC code of ethics.Preferred Qualifications:N/ACOMPANY:

KAISERLOCATION:

San Rafael, CaliforniaREQNUMBER:

1308223External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.

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