1. Review the content for each medical record as it relates to documentation and coding assignment and identify deficiencies as needed.
2. Assign diagnosis and procedure codes following guidelines and standard practice procedures for ICD-10-CM classification system.
3. Assign CPT/HCPCS codes following guidelines and standard practice.
4. Follow sequencing guidelines to establish principal and secondary diagnoses and procedures.
5. Assign appropriate modifiers to further identify services performed.
6. Abstract patient information from the medical record onto the computerized patient abstract database.
7. Investigate errors and warnings from encoding software and corrects accordingly. 
8. Transmit information from the abstract to the billing system.
9. Enter charges as appropriate per established processes. 
10. Maintain encoding software and coding references with updates when published. 
11. Participate in orientation and training of new employees into various coding roles. 
12. Attend continuing education sessions to maintain and enhance coding skills and meet requirements for certification.
13. Participate in utilization review and other organizational processes to evaluate documentation concerns.
14. Maintain a working knowledge of reimbursement methodologies and critical access guidelines to maximize reimbursement.
15. Review claim denials and collaborates with billing/denial staff to resolve. 
16. Routinely and systematically addresses assigned Excellian work queues.
17. Coding account types will be coded by Coding Specialist/RHIT according to the level of training as outlined (See Tiers below).
18. Demonstrate Standards of Excellence when other duties are assigned.

Lead Responsibilities if applicable:

• Direct and check the work of others.
• Participate in the orientation and/or training of employees and provide feedback to management.
• Coordinate the workflow among employees within the work area.
• Provide technical or functional directions and support to employees.
• Inform management on operational needs of the department.
• Assist with the creation of work schedules.
• Approve requests for time off, schedule changes, or additional ours/overtime and determine sick call replacement, according to a jointly pre-approved process, in the absence of a supervisor or manager.
• Excellent Customer Service and communication skills are essential for the lead position.
• Analyze and monitor all assigned work queues, identify error trends and develop training resources to improve accuracy.
• Work closely with all Revenue Cycle staff to identify and create account accuracy improvement projects.
• Serve as a communication liaison between revenue cycle staff for problem accounts and efficiencies.