Certified Coder - Lead

Job Title: Certified Coder - Lead 

Department: Health Information Management 
Reports To: Director of Health Information Management 

FLSA: Non-Exempt 

JOB SUMMARY: 
The Certified Coder – Lead plays a critical role in ensuring the accuracy, integrity, and compliance of coding practices across the organization. In addition to performing coding functions, this position provides leadership and oversight to the coding team by reviewing and resolving complex medical records, mentoring staff, and supporting quality improvement initiatives. The Lead serves as a key resource for coding compliance, documentation clarification, and denial resolution, while assisting leadership with workflow coordination and performance monitoring. 

ESSENTIAL FUNCTIONS: 

• Reviews medical records thoroughly to ensure accurate assignment of charges, diagnoses/procedures, and appropriate modifiers. 

• Abstracts documentation within the record into 3M Coding Software. 

• Queries providers regarding incomplete, missing, or vague documentation. 

• Codes all diagnoses/procedures in accordance with ICD-10-CM, ICD-10-PCS, CPT coding guidelines, and payer contracts. 

• Reviews and resolves complex coding cases and high-level documentation issues. 

• Provides guidance and support to coders, including mentoring, training, and serving as a resource for difficult coding scenarios. 

• Conducts quality reviews and monitors coding accuracy, productivity, and compliance with internal and external guidelines. 

• Assists with coding-related issues and denials received from billing, escalating systemic issues to leadership. 

• Collaborates with providers and departments to improve documentation practices and ensure accurate code assignment. 

• Responsible for Chargemaster maintenance and assists with state requirements and reports. 

• Partners with leadership in developing and implementing coding policies, workflows, and performance improvement initiatives. 

• Provides back-up coverage for transcription as needed. 

QUALIFICATIONS: 

• Minimum Education: 

• High School diploma or equivalent required. 

• Associate’s degree in Health Information Technology preferred. 

• Current coding certification through AHIMA or AAPC (RHIT, CCS, CPC, or equivalent). 

• Minimum Experience: 

• Three years of coding experience required; prior leadership, mentoring, or lead coder experience strongly preferred. 

• Knowledge of CPSI / Trubridge and RCM preferred. 

• Proficiency: 

• Inpatient, obstetrics, ancillary coding. 

• Infusion and injection coding. 

• E/M coding for Emergency Room professional/facility and hospital rounds. 

• Ability to analyze and resolve complex coding and documentation cases. 

• Strong communication, collaboration, and leadership skills. 

This job description is not intended as an all-inclusive list of responsibilities that may be assigned and is subject to change based on the needs of the organization.