Medical Coder - Lead
Luminis Health, Annapolis, MD, United States
Title
Medical Coder - Lead
Department
HIM - Medical Records
Reports to
Manager - Coding and Data Quality
Job Code/Cost Center
10000-50072-003015
FLSA Status
Non - Exempt
Position Objective
The Medical Lead Coder under the supervision of the Manager of Coding and Data Quality assists with oversight of daily Inpatient coding operations. This may include work volume and distribution, workflow evaluations and testing. The 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, resolve coding-related queries, and 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.
Ensure documentation supports the codes assigned and accurately reflects the services provided to maintain compliance with coding guidelines.
Analyze complex medical scenarios and make informed decisions regarding code selection based on the documentation provided.
Conduct regular audits and quality assurance reviews to monitor coding accuracy, identify areas for improvement, and implement corrective measures as needed.
Generate reports and provide coding-related data analysis to support healthcare management and decision-making.
Assist with the implementation of coding-related software, updates, and system enhancements to optimize coding processes.
Maintain a positive and collaborative working relationship with healthcare providers, billing staff, and other stakeholders to foster effective teamwork and communication.
Provide support during external coding audits, including cooperating with auditors, providing documentation, and addressing any findings or recommendations.
Outpatient Essential Job Duties
Review Outpatient medical records, including patient histories, examination findings, diagnoses, and treatment plans, to extract pertinent information for code assignment.
Assign accurate codes to diagnoses, procedures, and services rendered using coding systems such as ICD (International Classification of Diseases) and CPT (Current Procedural Terminology).
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, resolve coding-related queries, and 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.
Ensure documentation supports the codes assigned and accurately reflects the services provided to maintain compliance with coding guidelines.
Analyze complex medical scenarios and make informed decisions regarding code selection based on the documentation provided.
Conduct regular audits and quality assurance reviews to monitor coding accuracy, identify areas for improvement, and implement corrective measures as needed.
Generate reports and provide coding-related data analysis to support healthcare management and decision-making.
Assist with the implementation of coding-related software, updates, and system enhancements to optimize coding processes.
Maintain a positive and collaborative working relationship with healthcare providers, billing staff, and other stakeholders to foster effective teamwork and communication.
Educational/Experience Requirements
Required Minimum Education
High School diploma or equivalent and Medical Coding Education. Preferred bachelor’s degree in health information management, business administration or related field.
Required Minimum Experience
Three (3) years of verifiable, progressive coding experience. Preferred more than five (5) years of coding experience in an acute care hospital setting.
Required License/Certifications
Certification as a Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), or Certified Coding Specialist Physician-Based (CCS-P), or a Certified Coding Associate (CCA) required. Preferred Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA).
Working Conditions, Equipment, Physical Demands
Light work. Exerting up to twenty pounds of force occasionally, and/or up to ten pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
There is reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.
Pay Range
$26.10—$39.15 USD
Luminis Health Benefits Overview
Medical, Dental, and Vision Insurance
Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
Paid Time Off
Tuition Assistance Benefits
Employee Referral Bonus Program
Paid Holidays, Disability, and Life/AD&D for full-time employees
Wellness Programs
Employee Assistance Programs and more
Benefit offerings based on employment status
#J-18808-Ljbffr
Medical Coder - Lead
Department
HIM - Medical Records
Reports to
Manager - Coding and Data Quality
Job Code/Cost Center
10000-50072-003015
FLSA Status
Non - Exempt
Position Objective
The Medical Lead Coder under the supervision of the Manager of Coding and Data Quality assists with oversight of daily Inpatient coding operations. This may include work volume and distribution, workflow evaluations and testing. The 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, resolve coding-related queries, and 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.
Ensure documentation supports the codes assigned and accurately reflects the services provided to maintain compliance with coding guidelines.
Analyze complex medical scenarios and make informed decisions regarding code selection based on the documentation provided.
Conduct regular audits and quality assurance reviews to monitor coding accuracy, identify areas for improvement, and implement corrective measures as needed.
Generate reports and provide coding-related data analysis to support healthcare management and decision-making.
Assist with the implementation of coding-related software, updates, and system enhancements to optimize coding processes.
Maintain a positive and collaborative working relationship with healthcare providers, billing staff, and other stakeholders to foster effective teamwork and communication.
Provide support during external coding audits, including cooperating with auditors, providing documentation, and addressing any findings or recommendations.
Outpatient Essential Job Duties
Review Outpatient medical records, including patient histories, examination findings, diagnoses, and treatment plans, to extract pertinent information for code assignment.
Assign accurate codes to diagnoses, procedures, and services rendered using coding systems such as ICD (International Classification of Diseases) and CPT (Current Procedural Terminology).
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, resolve coding-related queries, and 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.
Ensure documentation supports the codes assigned and accurately reflects the services provided to maintain compliance with coding guidelines.
Analyze complex medical scenarios and make informed decisions regarding code selection based on the documentation provided.
Conduct regular audits and quality assurance reviews to monitor coding accuracy, identify areas for improvement, and implement corrective measures as needed.
Generate reports and provide coding-related data analysis to support healthcare management and decision-making.
Assist with the implementation of coding-related software, updates, and system enhancements to optimize coding processes.
Maintain a positive and collaborative working relationship with healthcare providers, billing staff, and other stakeholders to foster effective teamwork and communication.
Educational/Experience Requirements
Required Minimum Education
High School diploma or equivalent and Medical Coding Education. Preferred bachelor’s degree in health information management, business administration or related field.
Required Minimum Experience
Three (3) years of verifiable, progressive coding experience. Preferred more than five (5) years of coding experience in an acute care hospital setting.
Required License/Certifications
Certification as a Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), or Certified Coding Specialist Physician-Based (CCS-P), or a Certified Coding Associate (CCA) required. Preferred Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA).
Working Conditions, Equipment, Physical Demands
Light work. Exerting up to twenty pounds of force occasionally, and/or up to ten pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
There is reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.
Pay Range
$26.10—$39.15 USD
Luminis Health Benefits Overview
Medical, Dental, and Vision Insurance
Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
Paid Time Off
Tuition Assistance Benefits
Employee Referral Bonus Program
Paid Holidays, Disability, and Life/AD&D for full-time employees
Wellness Programs
Employee Assistance Programs and more
Benefit offerings based on employment status
#J-18808-Ljbffr