UNIVERSITY OF WASHINGTON

Specification for Class

CLINICAL DATA SPECIALIST TRAINEE

UW CODE AND REPRESENTATIVE GROUP

8363 (SEIU Local 925 Clerical Nonsupervisory)

CLASS SERIES CONCEPT

Provide International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and Ambulatory Procedure Code (APC) coding for patient health records; abstract data for quality assurance and the case-mix database; assess chart documentation to determine appropriateness of hospitalization of patients.

BASIC FUNCTION

Participate in training of graduated complexity for ICD, CPT and APC coding of medical records, data entry, abstracting, admission justification, utilization review, and/or length of stay procedures.

DISTINGUISHING CHARACTERISTICS

Under direct supervision, participate in systematic training for ICD, CPT and APC coding of medical records and data entry using various health information databases.

TYPICAL WORK

Participate in systematic on-the-job training to advance the learning of:

1.                     ICD and CPT coding of medical records;
2.                     entering and verifying assigned codes on an automated abstracting/coding system;
3.                     reviewing admissions using defined criteria for appropriateness of hospitalization;
4.                     monitoring patient length-of-stay and evaluate for variation from regulatory guidelines;
5.                     identifying and reporting all utilization review deviations and follow-up all reviews for continued stays;
6.                     designing studies and abstract data for quality assurance;
7.                     coordinating the monthly Coding Verification inservice meeting;
8.                     review of APC claims for accuracy of codes and modifiers;
9.                    
review of coding accuracy on outpatient clinic fee sheets;

Participate with other hospital departments in the maintenance of various health information database systems;

Prepare ad-hoc and statistical reports using a computer database;

Perform related duties as required.

MINIMUM QUALIFICATIONS - UW Contract Classified
DESIRABLE QUALIFICATIONS - Classified Non-Union

Certified or eligible for certification within one year of hire as a Registered Health Information Technician (RHIT) or Registered Health Information Analyst (RHIA)

OR

equivalent education/experience.

New Class: 4-18-88
Revise Class/Title: 9-25-92
Revise Class/Title: 9-1-02

CSR Class Conversion (mc): 06-01-05