Job Description

*** New Hires are eligible for a Sign-On Bonus***

The Health Information Coder I is an entry level coder with a basic knowledge and skill set to utilize ICD-10-CM, CPT and HCPCS classifications systems to code across various healthcare settings, including outpatient, emergency department, and ancillary services. This role ensures coding accuracy, compliance with regulatory guidelines, and adherence to UCSF policies, supporting proper reimbursement and revenue cycle integrity. The Coder I collaborates with healthcare providers, revenue cycle teams, and compliance departments to resolve documentation issues and maintain high standards of coding performance.

The employee will work eight (8) hours per day, excluding meal periods, on five (5) consecutive days within a workweek. The workweek schedule is set between the employee and the manager and may be scheduled to start any day of the week based on manager approval.

DEPARTMENTAL OVERVIEW

UCSF’s Health Information Management department maintains health records for all inpatient, outpatient, and same-day surgery services. These records are protected under HIPPA and California state law, ensuring privacy and confidentiality. The coding department at UCSF is responsible for translating detailed clinical documentation, such as diagnoses, procedures, and services into standardized alphanumeric codes that can be understood by all parts of the healthcare system. Its main purpose is to ensure accurate communication, billing, compliance, and data use across hospitals, clinics, insurers, and public health agencies.

***Note: We are offering a new hire sign-on bonus of $2,000. All external new hires who have not worked for a UC in the last 12 months are eligible. The bonus is payable after 30 days of continuous employment.

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

100

1. Assigns accurate ICD-10-CM, CPT, and HCPCS codes for diagnoses, procedures, and services based on documentation in the medical record.

2. Knowledge of Evaluation and Management code assignment.

3. Ensures coding compliance with federal regulations, payer policies, UCSF standards, and industry guidelines including LCD/NCD requirements.

4. Reviews medical records and abstracts necessary information, ensuring documentation supports assigned codes for billing and reimbursement.

5. Resolves coding edits, discrepancies, and denials, collaborating with appropriate departments to ensure accurate claim submission.

6. Maintains productivity and quality benchmarks achieving organizational accuracy standards and ensuring timely completion of coding assignments.

7. Participates in ongoing education and training, staying updated on changes in ICD-10-CM, CPT, HCPCS and regulatory compliance.

8. Works with revenue cycle teams, providers, and compliance staff to clarify documentation and coding-related issues.

9. Uses electronic medical records, coding software, and hospital billing systems to perform daily coding activities.

10. Report to a lead or manager.

11. Interact with internal and external UCSF Health staff and customers.

12. Satisfactory time and attendance

100%

(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)

REQUIRED QUALIFICATIONS

• High school graduation or G.E.D.

• 1-3 years of healthcare coding or related healthcare experience.

• Must pass the initial knowledge assessment test with a score of 80%.

• Must meet daily production requirement with minimal accuracy rate of 95%.

• Basic EHR and encoder skills

• Basic computer skills, including Windows, Word and Excel.

• Proven excellent communication and cooperative skills.

• Ability to analyze information, make decisions and exercise independent judgment.

• Ability to follow written directions.

• Ability to prioritize work and manage time effectively.

• Ability to meet deadlines and perform well under pressure.

• Knowledge of medical terminology, medical abbreviations, disease processes, anatomy and physiology.

• Knowledge of the ICD-10-CM, ICD-10-PCS and CPT classification systems.

REQUIRED LICENSES/CERTIFICATIONS

• Certified Outpatient Code (COC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or other coding certification.

PREFERRED QUALIFICATION

• Knowledge of HIMS database systems.

• Knowledge of HIMS procedures.