Job Description

MEDICAL CODER SENIOR
SUMMARY

The Medical Coder Senior performs full-level expert coding in the hospital’s health information management department. The senior coder assigns ICD (international classification of disease) codes and modifiers for diagnoses and procedures utilizing the hospital’s encoding software and appropriate procedural, terminology and health related common procedure coding books.

• An employee in this position may be called upon to do any or all of the following essential functions. These examples do not include all of the functions which the employee may be expected to perform.
• Performs full-level medical coding. Encompassing but not limited to inpatient coding and all entry and associate level coding.
• Analyses, researches and corrects complex data integrity issues including inpatient related cases. 
• Abstracts and collects pertinent patient information housed in the hospital’s database.
• Contributes to coding compliance and departmental objectives by providing leadership, mentoring and coding expertise.
• Assists and mentors associate and entry level coders in identifying and correcting data integrity issues within the electronic medical records system and subsequently facilitates corrections.
• Utilizes coding software and coding reference books to perform day-to-day functions and assist associate and entry level coders in honing and developing medical coding skills.
• Maintains accuracy for all coding and productivity standards. 
• Adheres to standard ethical coding guidelines established by professional health information management associations.

SCOPE AND LEVEL:

• Guidelines: Guidelines are generally but not always clearly applicable, requiring the employee to exercise judgment in selecting the most pertinent guideline, interpret precedents, adapt standard practices to differing situations, and recommend alternative actions in situations without precedent.
• Complexity : Duties assigned are generally complex and may be of substantial intricacy. Work assignment is performed within an established framework under general instructions but requires simultaneous coordination of assigned functions or projects in various stages of completion.
• Decision Making: Exercises judgment and discretion, and is responsible for determining the time, place and sequence of the work performed.
• Communications: Contacts with the public or employees where explanatory or interpretive information is exchanged, defended, and gathered and discretion and judgment are required within the parameters of the job function.
• Supervision Received: Performs work with minimal supervisory oversight. Under general supervision, the employee receives assignments and is expected to carry them through to completion with substantial independence. Work is reviewed for adherence to instructions, accuracy, completeness, and conformance to standard practice or precedent. Recurring work clearly covered by guidelines may or may not be reviewed.

MINIMUM QUALIFICATIONS:
Education, Experience, Licensure, Certification

• EDUCATION – High School Diploma or Equivalent
• EXPERIENCE – Five years of medical hospital coding and charging experience.
• EQUIVALENCY –
• CERTIFICATION(S ) - One of the following is required: Certified Coding Specialist (CCS); Certified Professional Coder (CPC); Registered Health Information Administrator (RHIA); Registered Health Information Technician (RHIT)
• LICENSURE –

PHYSICAL REQUIREMENTS:

• Audio-Visual : Hearing: Good
• Audio-Visual: Near Vision: Good
• General Activity: Sit: 2-4 hrs. per day
• Motion: Bend: Up to 1/3 of time
• Use of Hands/Feet: Precise Motor Function
• Weight Lifted/Force Exerted: Up to 30 pounds

WORK ENVIRONMENT:

• Mental and Emotional Requirements : Independent discretion/decision making.
• Mental and Emotional Requirements: Makes decisions under pressure.
• Mental and Emotional Requirements: Manages stress appropriately.
• Mental and Emotional Requirements: Works with others effectively.

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