Patient Records Abstractor II - Remote - 141045

UC San Diego Health's Revenue Cycle department supports the organization's mission to deliver outstanding patient care and to create a healthier world - one life at a time. We are a diverse, patient-focused, high-performing team with a commitment to quality, collaboration, and continuous improvement that enables us to deliver the maximum standard of care to our patients. We offer challenging career opportunities in a fast-paced and innovative environment and we embrace individuals who demonstrate a deep passion for problem-solving and customer service.

The Patient Abstractor reviews and analyzes medical records to identify documentation deficiencies and ensure compliance with The Joint Commission (TJC) standards, Title 22 regulations, Medical Staff Bylaws, Rules and Regulations, and Health Information Management (HIM) policies and procedures. This role serves as a primary liaison between deficiency analysis staff, management, clinical providers, and other key stakeholders to facilitate timely and accurate completion of medical records.

The Patient Abstractor assigns required documentation and dictation deficiencies, monitors record completion through the electronic health record (EHR) and legacy systems, and tracks outstanding deficiencies to ensure responsible providers meet record completion requirements within established timeframes. The role also supports physician billing and coding functions by assisting with the accurate assignment of billing-related documentation, which directly impacts physician Relative Value Units (RVUs).

Additionally, the Patient Abstractor ensures the appropriate routing of deficiency notifications and communications to providers and their respective departments. Acting as a key point of contact between HIM, clinical staff, and coding teams, this position helps resolve documentation and workflow-related issues while supporting effective communication across departments.

This role is responsible for troubleshooting electronic and technical issues related to electronic signature systems and coordinating resolution efforts with the appropriate technical and operational teams. Success in this position requires strong verbal and written communication skills, the ability to build collaborative relationships, and the capacity to clearly explain complex documentation, compliance, and workflow requirements to diverse audiences.

The Patient Abstractor may also provide support for other HIM functions, including maintenance of the Master Patient Index (MPI), scanning and indexing of patient records, document imaging workflows, and Release of Information (ROI) processes, as needed to support departmental operations and organizational goals.

• Graduation from High School or a GED with a demonstrated knowledge of the applicable medical terminology.

• Successful completion of AHIMA or AAPC accredited Health Information Tech/Management or Coding Program.

• Certified Professional Coder (CPC-A) or credentialed by AHIMA (RHIT)

• Experience coding physician, outpatient, inpatient, ancillary or surgical claims.

• Prior experience working in a hospital/physician office environment.

• Two (2) years of related hospital clerical experience; one of which must be in the type of work to be performed; or an equivalent combination of education and experience.

• Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification.

• Professional fee coding certification, such as CPC or CCS-P.

• Healthcare Environment Experience.

• Experience in Release of Information of medical records.

• Familiar with HIPAA and CMS Medicare Guidelines.

• Familiar with TJC (Joint Commission) and Title 22 Regulations.

• Experience with chart analysis in Epic.

• Experience working with transcription vendors.

• Experience working with Patient Identity/Data Integrity.

• Must be able to work various hours and locations based on business needs.

• Employment is subject to a criminal background check and pre-employment physical.