LEAD CODER, MEDICAL RECORDS

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.