Patient Records Abstractor 4 Ambulatory Surgery Coder

The Patient Care Services Coding and Billing Unit is responsible for data collection and the submission of professional and hospital charges for services provided by the Ambulatory Surgery department. Under the general direction of the Coding Management the incumbent is required to review medical record documentation for all ASU patient encounters and discuss with the physician/provider when discrepancies occur between coding and documentation. Responsibilities include collecting and analyzing documentation, assigning appropriate CPT, ICD-10 diagnosis to generate billing for services rendered. Incumbent will ensure compliance to all federal, state and carrier specific rules, regulations, and requirements, related to professional fee and technical services are followed. The coding unit assures that all records are analyzed for deficiencies as identified by JCAHO, CMS, Title 22, and the medical staff. All data abstraction and coding are performed using OSHPD, JCAHO, CMA, UHDDS and Title 22 documentation guidelines. Coded information if abstracted from the medical records of patients to generate a clinical patient database for the facility. This assures the maintenance and accuracy of diagnostic and procedural statistics for the facility as well as optimum appropriate reimbursement from third party payers, by the timely coding of diagnosis and procedures using the required classification systems.

Apply By 11/17/2025 at 11:59PM.

Qualifications

Minimum Qualifications - For full consideration, applicants are encouraged to upload license and/or certification if required of the position

• American Health Information Management Association (AHIMA) Certified Coding Specialist - Physician-based (CCS-P) or Certified Coding Specialist (CCS), or American Association of Professional Coders (AAPC) Certified Professional Coder (CPC) Certification or Certified Outpatient Coder (COC) Certification
• American Health Information Management Association (AHIMA) Certified Coding Specialist - Physician-based (CCS-P) or Certified Coding Specialist (CCS), or American Association of Professional Coders (AAPC) Certified Professional Coder (CPC) Certification
• At least 2 years of acute care, ED, and/ or ASU coding experience.
• Coding experience must include assignment of DRG, assignment and APC assignment.
• Familiarity with OSHPD, UHDDS, CMS and JCAHO documentation requirements
• Experience with and knowledge of instructional notations and conventions of ICD-9-CM, DRG, APC and CPT classification systems; and ability to follow the detailed guidelines related to their use in assigning single, and sequencing multiple, diagnosis and procedure codes for appropriate reimbursements and data collection.
• Ability to read handwritten and transcribed documents in the medical record, interpret information, and enter complete and accurate data into an on line encoding system.
• Comprehensive knowledge of medical diagnostic and procedural terminology required.
• College level understanding of disease processes, anatomy and physiology necessary to assign accurate codes using the ICD-9-CM and CPT coding conventions.
• Knowledge of Federal, State and local government regulations and requirements which pertain to patient care information and requirements for a complete medical record for deficiency chart analysis.
• Knowledge of third-party payor reimbursement requirements and an understanding of multi-medical specialties, encounters, and procedures in acute care, ED and ambulatory care settings.
• Ability to communicate technical and clinical information concerning patient care and classification systems at different levels, i.e. physicians, ancillary, and administrative personnel.
• Ability to apply policies and procedures regarding data security and confidentiality to protect the inappropriate release of information.
• Ability to exercise judgement with minimal supervision.
• Ability to be flexible & follow many different guidelines that change annually.
• Ability to assume responsibility for compilation of clinical data related to inpatient and outpatient encounters including diagnoses, procedures, physicians and services.
• Remains current with periodic updates of all coding manuals and guidelines in accordance with Federal, State and local regulations,
• Ability to manage time schedules, deadlines, multiple requests and priorities, and to maintain productivity.

Preferred Qualifications

• (AHIMA) Certified Coding Specialist - Physician-based (CCS-P) or (AAPC) Certified Professional Coder CPC highly preferred.

Key Responsibilities

• 90% - REVIEWS, ABSTRACTS AND CODES INPATIENT, OUTPATIENT, AND AMBULATORY SURGERY RECORDS TO ENSURE DATA QUALITY AND TO OPTIMIZE REIMBURSEMENT
• 5% - PROVIDE SUPPORT TO THE CODING UNIT
• 5% - PARTICIPATES IN EDUCATIONAL EXPERIENCES CONCERNING CODING AND ABSTRACTING ISSUES.

Department Overview

The Coding and CDI Department is a critical part of the healthcare organization, dedicated to improving patient care, supporting research, and facilitating education through the efficient management of medical records and clinical databases. The department, which consists of over 200 Full-Time Equivalents (FTEs) across diverse units, is responsible for ensuring the accuracy, accessibility, and compliance of patient information, which is crucial for clinical decision-making, billing accuracy, and regulatory adherence. The department includes key groups such as Inpatient and Outpatient Clinical Documentation Integrity (IP/OP CDI), All Coding Operations, the CDI Coding Quality Analyst Group, the Coding and CDI Clinical Analyst Team, and the Provider Advocate Team. Each of these teams plays a specialized role in supporting the organization's health information needs. IP/OP CDI focuses on ensuring that clinical documentation accurately reflects the complexity and severity of patient care, contributing to appropriate coding, billing, and reimbursement. All of Coding Operations ensures that all patient records are coded accurately according to industry standards and regulatory requirements, supporting billing processes and ensuring compliance. The CDI Coding Quality Analyst Group is responsible for monitoring and improving the quality of clinical documentation and coding processes to ensure accuracy and efficiency. The Coding and CDI Clinical Analyst Team focuses on the analysis and optimization of clinical data systems, ensuring that health information is easily accessible and accurate across the organization in collaboration with other department data analysts. The Provider Advocate Team collaborates directly with physicians and other clinical staff to ensure accurate documentation and smooth integration of clinical data into patient records. Together, these teams ensure that the department not only supports day-to-day clinical operations but also plays a key role in broader strategic initiatives. The Coding and CDI Department ensures that data integrity is maintained, healthcare regulations are followed, and operational workflows are optimized to support patient care and organizational efficiency. Through this multidisciplinary approach, the Coding and CDI Department significantly contributes to the organization's mission of delivering high-quality healthcare.

POSITION INFORMATION

• Salary or Pay Range: $51.07 - $63.46
• Salary Frequency: Hourly
• Salary Grade: 112
• UC Job Title: PAT RCDS ABSTRACTOR 4
• UC Job Code: 004716
• Number of Positions: 2
• Appointment Type: Staff: Career
• Percentage of Time: 100%
• Shift (Work Schedule): DAY
• Location: Remote Worksite (REMOTE)
• Union Representation: EX-Patient Care Technical
• Benefits Eligible: Yes
• This position is 100% remote

Benefits

Outstanding benefits and perks are among the many rewards of working for the University of California. UC Davis offers a full range of benefits, resources and programs to help you bring your best self to work, as well as to help you and your family achieve your health, wellness, financial and career goals. Learn more about the benefits below and eligibility rules by visiting either our handy or and our .

If you are represented by a union, benefits are negotiated between the University of California (UC) and your union and finalized in a contract. Read your bargaining unit's employment contract, stay abreast of current negotiations and learn about collective bargaining at UC: https://ucnet.universityofcalifornia.edu/labor/bargaining-units/index.html

• High quality and low-cost medical plans to choose from to fit your family's needs
• UC pays for Dental and Vision insurance premiums for you and your family
• Extensive leave benefits including Pregnancy and Parental Leave, Family & Medical Leave
• Paid Holidays annually as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
• Paid Time Off/Vacation/Sick Time as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
• Continuing Education (CE) allowance and Education Reimbursement Program as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
• Access to free professional development courses and learning opportunities for personal and professional growth
• WorkLife and Wellness programs and resources
• On-site Employee Assistance Program including access to free mental health services
• Supplemental insurance offered including additional life, short/long term disability, pet insurance and legal coverage
• Public Service Loan Forgiveness (PSFL) Qualified Employer & Student Loan Repayment Assistance Program for qualified roles
• Retirement benefit options for eligible roles including Pension and other Retirement Saving Plans. More information on our retirement benefits can be found

Physical Demands

• Standing - Occasional Up to 3 Hours
• Walking - Occasional Up to 3 Hours
• Sitting - Frequent 3 to 6 Hours
• Lifting/Carrying 0-25 Lbs - Occasional Up to 3 Hours
• Pushing/Pulling 0-25 Lbs - Occasional Up to 3 Hours
• Bending/Stooping - Occasional Up to 3 Hours
• Squ