The Health Information Management Tech I is required to have a full understanding and active participation in fulfilling the mission, vision and values of San Gabriel Valley Medical Center.  The employee shall support San Gabriel Valley Medical Center’s strategic plan and the goals and direction of the department Performance Improvement Plan (PIP).

The Health Information Management Tech I is an entry level position responsible to collect, maintain, and make available to authorized users timely, accurate, and complete patient health information.  The Health Information Management Tech I supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors.  The Health Information Management Tech I prioritize, locate, pull, assemble, electronically track, scan and see to the appropriate delivery of health information requested by other departments in accordance with established standards.  Health Information Management Tech I must at all times safeguard and protect the patient’s right to privacy by ensuring that only authorized individuals have access to the patient’s medical information and that all releases of information are in compliance with the request, authorization, company policy and HIPAA regulations.  

Duties and Responsibilities 

The HIM Coding Specialist I job summary includes but is not limited to: 

• Assign and sequence ICD-10-CM, ICD-10-PCS and CPT codes for all specialty patient types which may include outpatient, ambulatory surgery, and emergency room records
• Accurately code outpatient referred cases and ancillary visits (25 encounters per hour) 
• Accurately code outpatient ambulatory records (3 encounters per hour) 
• Accurately code and abstract Emergency Department records (7 per hour, including E&M level and injections and infusions)
• Accurately code Obstetrical and Neonatal records (5 per hour)
• Maintain coding accuracy performance above 95 percent by appropriately assigning ICD-10-CM and CPT codes according to guidelines
• Abstract clinical data, including discharge disposition, accurately after documentation assessment 
• Query physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes
• Select and assign revenue codes based on CPT codes, where appropriate
• Perform medical record review for the timeliness and completeness of clinical documentation
• Participates in continuing education activities to enhance knowledge, skills and keep credentials current

Minimum qualifications

• Knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting
• Knowledge of AHA Coding Clinic for ICD-10-CM/PCS
• Knowledge of AHA Coding Clinic for HCPCS
• Knowledge of HIPAA regulations and to complete work in compliance of these and other standards
• Ability to read and comprehend advanced medical terminology

• Effective verbal and written communication skills
• Effective organizational skills 
• Ability to use fax, copier, scanner and multiline phone system and other required work tools
• Ability to learn new equipment, systems and required processes in a fast paced environment
• Ability to work professionally, effectively, and efficiently in a team environment with customers, management and co-workers

Education/Training/Experience

• High School Diploma or equivalent
• Certified Coding Specialist credentials from AHIMA required
• Minimum of an Associates’ Degree in healthcare related discipline desired
• Minimum of two years coding experience in a hospital Health Information Management Department (may be substituted for credentials)
• Advanced computer skills including keyboarding and Microsoft desktop applications (Word, Excel, Outlook)

Licenses/Certifications

• Certified Coding Specialist (CCS) or RHIT/RHIA credentials from AHIMA