Patient Records Abstractor

Location: Fully Remote

Employment Duration: 3 months

Patient Record Abstractor fulfills a role as a Medical Coder for UCSF’s physician practices. They review patient records, discharge summaries, operative reports, and other clinical documentation to assign standardized codes for diagnoses, procedures, and services. They apply national and international coding classifications to ensure records reflect the care delivered, supporting accurate reimbursement and reliable clinical data. They have knowledge of Current Procedural Terminology (CPT), International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM), and Healthcare Common Procedural Coding System (HCPCS).

The role operates within a healthcare records or billing team and requires close liaison with clinicians, clinical coders, and administrative staff to resolve documentation queries. Coders must maintain currency with coding updates, compliance requirements, and professional standards, and participate in regular audits to monitor coding quality. Expectations include timely processing of case volumes while maintaining high accuracy, adherence to confidentiality and information governance standards, and contribution to process improvements that enhance data quality and coding efficiency.

The Faculty Practice Revenue Management Operations (FPRMO) department is responsible for physician-based coding for UCSF faculty. The team ensures accurate code assignment for professional services delivered across UCSF locations, affiliated community hospitals, off-license practices, and ambulatory clinics.

FPRMO supports a diverse group of providers, including physicians, nurse practitioners, and advanced practice providers, across a wide spectrum of specialties within an academic medical center environment. These specialties include Neurosurgery, Cardiovascular Services, OB/GYN, Gender Reassignment, Rheumatology, and Plastic Surgery.

FPRMO plays a critical role in the revenue cycle by delivering precise and compliant coding for approximately 1.6 million patient encounters annually, supporting both regulatory requirements and optimal reimbursement.

Key Responsibilities:

• Work in moderate work queues daily as defined by UCSF leadership.
• Work in simple work queues as needed.
• Work RFI and edit work queues as needed.
• Maintain or exceed a 95% accuracy rate.
• Maintain productivity standards as defined by UCSF leadership.
• Work proactively with divisions in areas of specialization to assure appropriate revenue cycle practices and compliance with internal and external regulations.
• Code intermediate procedures/accounts requiring advanced knowledge in charge capture, workflow, hospital operations, authorizations, and the revenue cycle.