Lead Coder

As an Inpatient or Outpatient Coder, you will work under general supervision to assign diagnostic and procedural codes to patient charts of moderate to high complexity levels using ICD-9 and CPT, HCPCS, and any other designated coding classification system in accordance with coding rules and regulations.

Essential functions include but are not limited to:

  • Reviews medical records for the determination and accurate assignment of all documented diagnoses and procedures.
  • Assigns and sequence codes based on medical record documentation.
  • Assigns appropriate discharge disposition.
  • Abstracts and enters coded data and designated quality management data for hospital statistical and reporting requirements.
  • Communicates documentation improvement opportunities and coding issues (discrepancies, physician queries, etc.) to the appropriate personnel for follow up and resolution.
  • Serves as a functional resource for entry-level coders and mentors/trains other coders as needed.
  • Codes all types of patient records (i.e., inpatient, outpatient with the exception of specialty coding).

Mandatory Requirements

  • Registered Health Information Technician (RHIT)
  • Registered Health Information Administrator (RHIA)
  • Certified Coding Specialist (CCS)
  • Minimum of two years technical coding experience that includes inpatient and/or outpatient
  • Additional credentials such as CGCS, CPC-H or CPC-C preferred
  • Experience in computerized encoding and abstracting in a Windows-based environment preferred