LEAD CODER, MEDICAL RECORDS
Job Description
Summary
Reviews patient medical records for relevant diagnostic and procedure information and assigns corresponding codes according to standard coding guidelines maintaining productivity. Assists with the maintenance of various patient indexes and databases. Provides patient information retrieval assistance to researchers and others as needed.
Essential Responsibilities and Duties
1. Reviews patient medical records for all relevant diseases and assigns corresponding lCD codes according to standard coding guidelines.
2. Utilizes, interprets and translates clinical documentation from the medical record into diagnostic and procedural codes; abstracts data into computer data base using 3M System.
3. Responsible for thoroughly knowing and utilizing all coding systems both inpatient and outpatient according to the most recent rules, regulations and conventions.
4. Contacts physicians as necessary to request more complete information and/or clarification in order to completely code the patient records.
5. Maintains an accurate and timely computerized database utilizing prescribed abstract format.
6. Prepares or assist with the preparation of statistical or other special reports relating to patients, diseases and treatments.
7. Performs audits, quality checks, provides in-service and arrange/facilitate training.
8. Supervises direct reports, including interviewing, selecting, training, motivating, evaluating.
9. Follows all Hospital related policies and procedures.
10. Participates in self and others’ education, training and development, as applicable.
11. Performs all other related duties, as assigned.
Education
Bachelor’s or Associate Degree/ Diploma in Medical Records Management or other Medical Records related discipline is required.
Experience Required
Three (3) years of related experience with Bachelor’s Degree or five (5) years with Associate Degree/ Diploma is required.
Other Requirements(Certificates)
* Completion of Hospital approved Coder Training Program is required.
* Certified Coding Specialist (CCS) certification is preferred.
