The Lead Medical Coder role involves coding all patient types, including inpatient, swing bed, same-day surgery, ancillary, ambulatory, and provider-based clinics. This individual mentors, trains, and cross-trains coding staff, including newly hired personnel. Key duties include reviewing documentation to assign appropriate CPT/HCPCS and ICD-10-CM-PCS diagnosis codes and procedures for hospital and physician services in both inpatient and outpatient records.

Responsibilities include ensuring coding compliance, conducting internal audits and quality reviews to maintain coding accuracy, assisting with productivity reporting, coding complex accounts using encoder software, validating charges, and resolving moderate to complex coding problems. The role requires tracking documentation and charge issues for timely coding, consistently meeting quality and productivity standards, maintaining confidentiality, and staying current with coding and reimbursement guideline changes.

Candidates must have comprehensive knowledge of medical terminology, anatomy and physiology, ICD-10-CM/PCS, CPT/HCPCS, DRG/APC grouping principles, and experience with coding references, encoder software, and electronic health records. Effective communication with clinical personnel and participation in ongoing education and certification programs are expected.

Education and Certification:

High school diploma or equivalent with Medical Coding education; bachelor's degree preferred in Health Information Management, Business Administration, or related field.
Minimum of 3 years progressive coding experience; preferably over 5 years in an acute care hospital.
Certified Coding Specialist (CCS) or equivalent certification required.

The position demands professionalism, ethical behavior, accountability, participation in performance improvements, and adherence to the company's code of conduct and safety requirements.