Patient Records Abstractor 4

Under the general direction of the Supervisor, incumbent performs abstracting of medical services provided by UCDHS and affiliates. Incumbent identifies all billable services, CPT-4, ICD-10, and HCPCS codes for billing purposes to government agencies, insurance companies and patients. Incumbent is responsible for the accuracy of above procedure and diagnosis coding relative to corresponding documentation and standards. Incumbent will ensure compliance to all federal, state and carrier specific rules, regulations and requirements related to professional fee services are adhered to.

Apply By 11/13/2025 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

• Working knowledge and experience abstracting and coding using ICD-10 and CPT-4 codes
• Comprehensive knowledge of medical diagnostic and procedure terminology.
• Knowledge of disease processes, anatomy and physiology necessary for assigning accurate codes.
• Ability to follow ICD-10 and CPT guidelines in assigning codes to visits and procedures.
• Ability to follow CMS and UCDHS teaching physician guidelines in applying evaluation and management codes.
• Knowledge of Federal, State and local government regulations and requirements, which pertain to patient care information.
• Knowledge of third party payor reimbursement requirements and reimbursement methodologies.
• Ability to interpret and communicate professional fee coding information to physicians and other UCDHS staff.
• Ability to manage time schedules, deadlines, multiple requests, priorities and maintain productivity.
• Excellent written and oral communication skills.
• Problem solving and decision making skills to independently define a problem, identify the resources available, create viable solutions and to take the necessary action.
• Organizational skills to maintain work area and in progress/pending work /patient lists, in such a way that the information is easily retrievable.
• Abides by the American Health Information Managements Association's established code of ethical principles to safeguard the public and contribute within the scope of the profession to quality and efficiency in health care, thus promoting ethical conduct.
• Abides by all compliance principles regarding fraud and abuse in the reimbursement environment.

Key Responsibilities

• 40% - Assign Appropriate Diagnosis and Procedure Codes
• 40% - Analyze Records and Documents to Determine Nature of Professional Services Rendered
• 10% - Physician Feedback
• 5% - Daily Reconciliation Review
• 5% - Monthly Reconciliation Review

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: 3
• 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 Benefits Summary for UC Davis Health Employees or Benefits Summary for UC Davis Employees and our Benefits Page.

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 here

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
• Squatting/Kneeling - Occasional Up to 3 Hours
• Twisting - Occasional Up to 3 Hours
• Reaching overhead - Occasional Up to 3 Hours
• Keyboard use/repetitive motion - Frequent 3 to 6 Hours

Mental Demands

• Sustained attention and concentration - Frequent 3 to 6 Hours
• Complex problem solving/reasoning - Occasional Up to 3 Hours
• Ability to organize & prioritize - Frequent 3 to 6 Hours
• Communication skills - Frequent 3 to 6 Hours
• Numerical skills - Occasional Up to 3 Hours
• Constant Interaction - Frequent 3 to 6 Hours
• Customer/Patient Contact - Frequent 3 to 6 Hours
• Multiple Concurrent Tasks - Frequent 3 to 6 Hours

Work Environment

UC Davis is a smoke and tobacco free campus effective January 1, 2014. Smoking, the use of smokeless tobacco products, and the use of unregulated nicotine products (e-cigarettes) will be strictly prohibited on any UC Davis owned or leased property, indoors and outdoors, including parking lots and residential space.

Special Requirements - Please contact your recruiter with questions regarding which activities apply by position

• This is a critical position, as defined by UC Policy and local procedures, and as such, employment is contingent upon clearing a criminal background check(s) and may include drug screening, medical evaluation clearance and functional capacity assessment
• This position is designated as a mandated reporter under CANRA and UC policy, and employment is contingent on compliance with applicable policies, procedures and training requirements

Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.

A Culture of Opportunity and Belonging

At UC Davis, we're committed to solving life's most urgent challenges and building a healthier, more resilient world. We believe in growing through every challenge, continually striving to improve, and welcoming new perspectives that strengthen our community. We recognize that a vibrant and innovative organization values both individual strengths and shared purpose. The best ideas often emerge when people with different experiences come together.

As you consider joining UC Davis, we invite you to explore our Principles of Community, our Clinical Strategic Plan and strategic vision for research and education. We believe you belong here. The University of California, Davis is an Equal Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age or protected veteran status.

To view the University of California's Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

Because we want you to feel seen and valued, our recruitment process at UC Davis supports openness and authenticity. Research shows that some individuals hesitate to apply unless they meet every qualification. You may be an excellent fit for this role-or the next one. We encourage you to apply even if your experience doesn't match every listed requirement. #YouBelongHere

To learn more about our background check program, please visit: https://hr.ucdavis.edu/departments/recruitment/ucd/selection/background-checks