Inpatient Coder

By | December 11, 2022

Inpatient Coder

Primary Location Santa Clara, California

Job Number 1112448

Date posted 12/10/2022


Job Summary:

The Inpatient Coder is accountable for accurately coding and abstracting inpatient cases or services (diagnosis, conditions, and procedures) from medical record documentation, working under direct supervision. Use the relevant ICD-CM, ICD-PCS, CPT, HCPCS, and other specialty systems to assign codes and modifiers as required by the diagnostic category. When required, the inpatient coder is expected to code and abstract complex hospital outpatient visits (CHOY), hospital ambulatory surgery, emergency department, and observation services (OBS).

The ICD-CM Official Guidelines for Coding and Reporting, the Coding Clinic published by the American Hospital Association, the ICD-CM, ICD-PCS, CPT, and HCPCS code book, CPT Assistant, NCCI Edits, CMS, OSHPD, and Kaiser Permanente's organizational and institutional coding guidelines must all be followed when performing any work.

Significant Duties:

  • Coding and abstracting: Examining the paperwork in medical records to find the diagnoses and procedures that need to be coded.
  • Organizes and prioritizes work assignments independently to make sure that records are coded on time and correctly in accordance with regulatory criteria.
  • Uses the ICD-CM, ICD-PCS, CPT, and HCSPCS coding classification systems to code all pertinent diagnoses and treatments from the medical record.
  • Accountable for arranging diagnoses and treatments in compliance with CPT, Uniform Hospital Discharge Data Set, ICD-CM, ICD-PCS, Medicare rules, and other suitable classification systems.
  • Determines whether the DRG is appropriate for each instance and examines DRG inconsistencies to ensure that each case is properly grouped.
  • Confirms and extracts the pertinent information from the medical records in accordance with the specifications for data submission and reporting.
  • Update data as necessary.
  • Assures that all abstracted data adheres to the standards set forth by the TJC, OSHPD, CMS, and regional and local KP policies.
  • Prior to data submission or coding completion, ensures the accuracy and integrity of data abstracted and coded based on medical record evidence.
  • Interacts with doctors to clarify and accurately record diagnostic and therapeutic information about patients.
  • By satisfying the coding/abstracting productivity/quality standards specified for the Inpatient Coder role, one can guarantee on-time data completion.
  • Interacts with doctors to clarify and accurately record diagnostic and therapeutic information about patients.
  • By satisfying the coding/abstracting productivity/quality standards specified for the Inpatient Coder role, one can guarantee on-time data completion.
  • Maintains and complies with rules and procedures for the confidentiality of all patient records. Confidentiality/Security of Systems.
  • Demonstrates an understanding of system privacy and security, as well as related policies and procedures for ensuring the security of the system's data.
  • Performs additional duties as directed.

Read also employee expected conduct for this job

Basic Qualifications:


Within the previous five years, three years of continuous hospital coding experience.


A high school diploma or GED is required, as well as proof that you have taken courses in medical terminology, anatomy, physiology, current ICD-CM, ICD-PCS, and CPT coding rules, as well as the progression of diseases, from an accredited institution.

License, Certification, and Registration:

Registered Health Information Technician Certificate OR Registered Health Information Administrator Certificate OR Certified Coding Specialist.

Additional Requirements:

  • Basic familiarity with and proficiency with computer keyboard and mouse.
    achieve a minimum KP Inpatient Coding score of 75%.
  • Must be capable of achieving the productivity and quality requirements set forth for the position.
  • The capacity to interpret the clinical information in a health record into code.
  • In order to interpret general medical categories for inpatient care, one must have demonstrated an understanding of anatomy, physiology, medical terminology, and disease processes.
  • Demonstrated understanding of the review of cases for coding compliance and quality.
  • Basic understanding of reimbursement procedures and customs, as well as laws and regulations governing the suitable and current coding classifications.
  • Being able to explain diagnoses, treatments, and the order of diagnoses in communication with doctors.
  • Must keep up coding certification and finish necessary Continuing Education (CE) units.
  • The AHIMA and AAPC code of ethics must be followed.
  • Applicants must be prepared to work in a labor-management partnership setting.

Preferred Qualifications:

Primary Location: California, Santa Clara, Santa Clara Hospital

40 scheduled hours per week, day shift

Mon, Tue, Wed, Thu, and Fri are workdays.

Working Schedule begins: 7:30 AM

The workday ends at 4:00 PM

Time commitment: full-time

Position Type: Regular

Oakland Reg – 1800 Harrison – Hospital Coding Operations – 0208 Employee Status: Regular Employee Group/Union

Affiliation: A01|SEIU|United

Health workers Job Level: Individual Contributor

Kaiser Permanente is an equal-opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

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