Medical Records Coder Senior

Under general supervision and according to established procedures, provides technical support to the Inpatient Coding Staff and coordinates daily workflow based on the needs of the department. Provides departmental statistics such as monitoring and tracking inpatient coder productivity and uncoded figures. Collaborates with Coding Manager and Coding Educator to identify and resolve coding issues. Serves as the primary contact for inpatient coding related questions for outside departments. Reports aged accounts to the Director of Medical Records and Coding Manager and follows up with Medical Records Staff or Physicians to obtain required documentation timely. Provides coding support as directed.

Analyzes patient medical records to identify diagnoses and procedures, assigning proper ICD 9 CM and HCPCS codes by referencing coding manuals and materials. Applies uniform hospital discharge data set definitions to select principal diagnoses and procedures. Applies sequencing guidelines according to official coding rules. Assesses adequacy of medical documentation to support codes and consults physicians to clarify as needed. Answers questions regarding coding principles, DRG assignment, and prospective payment system. Assists various departments with coding and DRG issues.

Maintains professional growth through educational programs and stays updated on developments in medical record technology. Adheres to safety training requirements and hospital exposure control plans. Demonstrates professionalism and respect in interactions. Promotes effective teamwork and facilitates department goals. Acts as liaison with lead technicians, provides performance feedback, performs quality monitoring, and works on quality improvement initiatives.

Qualifications include an Associate's degree or equivalent in Medical Information Technology with coursework in medical terminology, anatomy, physiology, disease processes, ICD 9 CM coding, and prospective payment. Requires 2 years of coding experience in an acute care setting. Preferred certifications include Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist—Physician Based (CCS-P), or Certified Coding Specialist (CCS), all from AHIMA.