Coder III - Per Diem

Clerical Fremont, California

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Description

Salary Range: $54.72 - $74.94 + applicable differentials

Job Description

Division: Revenue Cycle

Job Title: Coder III – Per Diem

Position Summary

Job Code: 562

Coder III – Per Diem is a senior-level coding professional responsible for

accurately assigning ICD-10-CM, ICD-10-PCS, and CPT/HCPCS codes for

complex inpatient and outpatient encounters. This role ensures precise DRG

assignment, optimal reimbursement, and compliance with federal, state, and

commercial payor regulations. The Coder III serves as a subject-matter

expert and provides guidance to clinical documentation, coding staff, and

revenue cycle leadership to support accurate charge capture and reduce

denials. In addition to performing the essential functions listed below, may

also be assigned other duties as required.

Statement of Accountability

Reports to: Director of Health Information Management

Qualifications

1. Education

• Education

Required:

• Licensure

• Work Experience

• Skills/computer/ specific technical

•

Associate of Arts (AA) or Associate of Science (AS) degree in

Health Information Technology.

▪ Other qualifications, miscellaneous

2. Licenses/Certifications

Specify if qualifications are Required

or Preferred

Required:

•

Registered Health Information Technician (RHIT) and Certified

Coding Specialist (CCS) or Certified Inpatient Coder (CIC).

Desired:

•

Registered Health Information Administrator (RHIA).

3. Work Experience

Required:

•

Previous ICD-10 coding experience in the Inpatient Hospital

environment.

•

Proficiency with ICD-10-PCS for surgical coding.

Experience with DRG validation and reconciliation.

Knowledge of medical terminology.

Minimum of three (5) years of experience in inpatient acute care

coding.

Desired:

•

Previous Health Information Management Department

experience.

•

Experience with electronic medical records.

4. Skills/computer/specific technical

Required:

•

Working knowledge of ICD-10 and CPT guidelines, conventions,

and coding systems.

•

Working knowledge of data collection systems for medical

records.

Job Description Template – Revised 12/1/2025

•

Familiarity with encoder tools and EHR systems (Epic experience

preferred).

Familiarity with Joint Commission, OSHPD and Title 22

regulations regarding medical records.

Comprehensive understanding of CMS, state regulations, and

commercial payor policies.

Detailed understanding of MS-DRG and APR-DRG

methodologies.

Ability to prepare written reports clearly and timely.

5. Other qualifications –

Ability to work well and communicate effectively with persons of

•

varying educational and cultural backgrounds.

Essential Job Responsibilities

Achieving Results

Key Components: assess, plan,

evaluate, demonstrate initiative,

quality of work, productivity

1. Assign accurate and compliant ICD-10 CM/PCS and CPT/HCPCS codes

for complex inpatient (including ICU, Trauma, and surgical) and high

acuity outpatient encounters.

2. Validate and assign MS-DRGs and APR-DRGs, ensuring clinical and

coding accuracy.

3. Determines, records, and abstracts other required data according to

applicable State, federal, or hospital requirements

4. Review provider documentation for completeness, specificity, and

compliance with coding standards (AHA, AHIMA, CMS).

5. Identify documentation gaps and initiate compliant provider queries to

clarify diagnoses, procedures, and severity.

6. Based on case mix, codes approximately 22 – 25 total cases per hour.

Demonstrates Skill

1. High level of accuracy and attention to detail - Codes records with 97%

accuracy rate; performs DRG assignment as appropriate, with accurate

case mix index data.

2. Ability to interpret complex clinical documentation - Records abstracted

data in accordance with published standards with 97% accuracy.

3. Strong analytical and problem-solving skills.

Key Components: competency, job

knowledge, organizational skills,

analytical skill, management of

information, employee & patient safety

4. Submits accurate and non-leading physician queries.

5. Adheres to coding guidelines and regulations.

6. Support revenue cycle initiatives, payor audits, and denial mitigation

strategies.

Planning & Coordinating

Key Components: delegates, decision

making, problem solving, management

of resources

1. Communicates changes in work volume and backlog to supervisor.

Professionalism

1. Displays good judgment and a practical approach to problem solving.

2. Complies with hospital’s Patient First ethic at all times.

3. Maintains confidentiality of all hospital information. Safeguards protected

health information from any intentional or unintentional disclosure.

4. Demonstrates teamwork and responds promptly to requests for help from

co-workers.

Key Components: dependability,

interpersonal skills, teamwork, patient

first ethic, customer service,

communication skills,

punctuality/attendance, receptiveness

to criticism, judgment, confidentiality

5. Partner with CDI, Billing, Revenue Integrity (charge capture), and

Compliance teams to resolve coding or documentation issues.

6. Displays courtesy to others at all times. Is considerate of others cultural

and spiritual needs.

Job Description Template – Revised 12/1/2025

7. Reports to work as scheduled, in compliance with hospital attendance

and punctuality policies.

8. Communicate effectively with physicians and clinical leaders on best

practices for documentation.

Improving the Organization

Key Components: performance

improvement, quality initiatives

1. Participates in performance improvement activities as required.

2. Follows safety policies at all times, helps to maintain a safe workplace.

Self-Development

Key Components: maintain

license/certification, education and

training

1. Completes annual mandatory events as required.

2. Maintain professional certifications.

3. Works to improve knowledge on an ongoing basis.

Regulatory Compliance

Key Components: JCAHO, Title 22,

OIG, HIPAA, State/Federal laws,

hospital policies

1. Complies with all applicable laws and standards in regards to

confidentiality, privacy and security.

2. Complies with department and hospital policies and procedures.

Prepared by:

Title: Director of HIM/Coding Date: 12/3/25

Lucy Young

Approved by:

Title: VP Revenue Cycle

Date:

Personnel Office Review:

Revised Date: 4/11, 9/15, 1/16, 12/25

Job Description Template – Revised 12/1/2025

Physical Requirements

Job # 562 Job Title Health Information Technician

1. Physical Activities – General description. Show average time (0 – 8 hours) per workday.

a. Sitting:

None/minimal (0-1)

Occasional (1-2)

Frequent (3-4)

Continuous (5+ Hrs)

b. Walking:

c. Standing:

d. Bending:

e. Squat, kneel,

crawl:

2. Weight lifted / force exerted. Show average time (0 – 8 hours) per workday:

a. 0 -25 lbs. (light):

None/minimal (0-1)

Pushing/Pulling

Occasional (1-2)

Frequent (3-4)

Continuous (5+ Hrs)

b. 26 - 50 lbs. (med):

c. 51 + lbs. (heavy):

d. Describe type of activity:

Reaching above shoulder level

Lifting

Carrying.

e. Details of heaviest item/activity: Medical records

3. Repetitive use of hands. Show average (0 – 8 hours) / workday:

a. Both hands:

b. Dominant only:

c. Dexterity:

None/minimal (0-1)

Simple grasping

Occasional (1-2)

Power grasping

Frequent (3-4)

Fine manipulation.

Continuous (5+ Hrs)

Continuous (5+ Hrs))

Describe any special activity: Computer work and handling charts.

4. Repetitive use of feet (other than walking/standing), i.e. foot control. Show average time (0 – 8 hours)

workday:

Right

Left

Both

None/minimal (0-1)

Occasional (1-2)

Frequent (3-4)

Continuous (5+ Hrs)

Describe any special activity: None.

5. Vision requirements:

Basic Vision Requirements; including Close Vision (clear vision at 20 inches or

less) and Distance Vision (clear at 20 feet or more).

Specific Vision Requirements:

Color Vision (ability to identify and distinguish colors)

Peripheral Vision (ability to observe up/down or left/right while eyes are fixed on a given point)

Depth Perception (three-dimensional vision; ability to judge distances and spatial relationships)

Describe any special vision requirement: None.

6. Hearing requirements:

Basic Hearing Requirements; including ability to hear alarms and pages,

ability to hear communications, requests or instructions from patients, staff or public.

Describe any special hearing requirement: None.

7. Work Environment - This job requires exposure to the following environmental conditions:

Blood or body fluids

Wet, humid conditions (non-weather) f.

Work near moving mechanical parts

Fumes or airborne particles

Toxic or caustic chemicals

Outdoor weather conditions

Extreme cold (non-weather)

Extreme heat (non-weather)

Electrical shock risk.

Risk of radiation

Vibration

l. Noise level for work environment is:

Very Quiet

Quiet

Moderate

Loud

Very Loud

8. Other (if applicable):

Job Description Template – Revised 12/1/2025

Job Hazard Analysis

Department: HIM

Job Code: 562

Hazards Which May Be Encountered

Injury

Methods To Prevent Injuries

Lifting Objects/Patients

Back Injuries

Understand A&P of back, causes of back pain, preventive approaches, use of aids

when lifting.

Hernias

Preventive measures when lifting and use aids when lifting.

Avoid undue speed. Use handrails. Clean up spills immediately.

Slip/Trip/Falls

Contusions, Sprains,

Strains

Fires & Natural Disasters

Burns & All Types of

Injuries

Recognize possible causes of fires. Smoking materials, faulty equipment.

Employees should educate patients. Compressed gasses are flammable & under

pressure so must be handled with care. Workers need to be familiar with disaster

plans and know exit routes.

Electrical Hazards

Assaults

Shocks & Burns

Be aware of unsafe equipment and appliances. Attend electrical safety classes

and seek assistance if any unsafe areas are noted.

Minor Injury to Death

Employees need to be cognizant to potential dangers to ensure safety. Awareness

of existing security measures and defensive behavior can protect employee from

assaults.

Needles & Sharps

Cuts, Punctures,

Lacerations

Sharps should be discarded in designated containers. Employees should exam &

handle soiled linens & similar items as if they contained hazardous items.

Obstacles & Broken Objects

Abrasions, Contusions, Arrange furniture to allow free movement about the room. Keep doors & drawers

and Lacerations

closed when not in use. Clean/discard broken objects properly (i.e. broken glass

should be swept up - not picked up with fingers).

Possible Exposures to Infections

Hepatitis/Tuberculosis/Cytomegalovirus/Varicella/AID

S/Herpes/Staph Infections, Lice/Scabies/Rubeola

Infection

Use Infection Control procedures as defined in Infection Control manual. These

include handwashing, protective clothing, knowing the risks. Label linens and

wastes properly.

Possible exposure to acids & other chemicals used

within the hospital

Refer to MSDS's

Employees should follow procedures as explained in their department Hazardous

Material training and refer to MSDS's before using/handling any chemical. Follow

procedures and do not use any chemical without proper labeling.

Job Description Template – Revised 12/1/2025

Hazards Which May Be Encountered

Injury

Methods To Prevent Injuries

Latex

Dermatitis to death

Alert supervisor if you feel that you are allergic to latex materials. Use non-latex

gloves for sterile procedures.

Soaps, Detergents, Cleaning Solutions

Ergonomic Problems

Dermatitis

Follow Departmental procedures. Protective clothing is available if Dept. is unable

to substitute agents that do not cause dermatitis.

Wide Variety of

Musculoskeletal

nervous disorders

Body mechanics, positioning of equipment/furniture, and repetitive actions can

cause employees to experience a variety of physical problems. Employees should

follow safe body mechanics as described in hospital education. Employees are

encouraged to seek assistance from their supervisor if they feel a task is causing

them to experience physical problems. Work site evaluation may be indicated and

this should be discussed with manager.

Possible Chemical Exposure

Refer to MSDS's

Employees work with a variety of chemicals within the lab setting. Employees

receive training upon hire and also are expected to review the Chemical Safety

Plan yearly. Employees are expected to follow safe working procedures as

instructed.

Possible exposure to radiation

Sterility, Cancer,

Shortened Life

Expectancy

When appropriate, employees should wear film badges (they are monitored

routinely) and use lead aprons, gloves, or shields. Identify and appropriately

manage radiation therapy patients and their secretions.

Possible Exposure to Chemotherapeutic Agents

Exposure to Video Display Terminals

Refer to MSDS's

Employees involved in preparation or administration of chemotherapy drugs have

potential for exposure. Employees must undergo training in their department and

should follow procedures as directed.

Eye strain & stress in

It is unknown if significant visual dysfunction results from long-term use of VDT's.

addition to ergonomic Problems may be controlled with control of lighting and glare, the color contrast,

complaints

and workers should have adequately corrected vision. Employees should seek

assistance from their supervisor if they feel VDT is causing problems for them.

Job Description Template – Revised 12/1/2025

Washington Hospital Health System does not utilize any form of electronic chatting, such as Google chat for the purposes of interviewing candidates for employment. If you are contacted by any entity or individual attempting to engage you in this format, do not disclose any personal information and contact Washington Hospital Healthcare System.

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Coder III - Per Diem

Description

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