Medical Coder - Lead

Position Objective

The Medical Lead Coder under the supervision of the Manager of Coding and Data Quality In accordance with Luminis Health coding guidelines, ICD-10-CM Official Coding Guidelines for Coding and reporting and other authoritative resources assists with oversight of daily Inpatient coding operations. This may include work volume and distribution, workflow evaluations and testing. This position may also include reviewing and reconciling reports, providing coding training within the Coding Department, and performing research on coding issues.

Inpatient Essential Job Duties

• Review Inpatient medical records, including patient histories, examination findings, diagnoses, and treatment plans, to extract pertinent information for code assignment. Assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology and pathophysiology/disease processes. Ensure compliance with coding guidelines, conventions, and regulatory requirements, including adherence to HIPAA privacy regulations.
• Utilize coding references, software tools, and electronic health records (EHR) to facilitate accurate and efficient code assignment.
• Maintain a high level of accuracy in code assignment to prevent claim denials, billing errors, and potential legal issues.
• Stay updated with coding changes, industry trends, and regulatory updates to ensure coding practices align with the latest guidelines and requirements.
• Collaborate with healthcare providers, billing staff, and other stakeholders to clarify documentation, to resolve coding-related queries, and to ensure accurate and timely claim submission and reimbursement.
• Participate in ongoing education, training, and certification programs to enhance coding proficiency and maintain credentials.
• Uphold professional ethics, integrity, and confidentiality in handling patient information.
• Communicate and collaborate with healthcare providers to clarify documentation, obtain necessary information for accurate code assignment, and resolve coding-related queries.