JOB SUMMARY: The Health Information Management Lead Coder is responsible for the accurate assignment of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes for inpatient, outpatient, surgical, and ancillary services. This position serves as a coding subject matter expert and collaborates with clinical, revenue cycle, quality, and physician teams to ensure complete and accurate clinical documentation and code assignment as needed. The Health Information Management Lead Coder reports directly to the Director of Health Information Management QUALIFICATIONS: Education:a.) Graduate of accredited Health Information Management program. Licensure/Certification: a.) Required: RHIA, RHIT, CCS, CPC or other AHIMA/AAPC certifications. Work Experience: a.) 3-5 years inpatient coding experience using ICD-10/PCS, CPT, and HCPCS. b.) Health Information Management records work experience. RESPONSIBILITIES/JOB DUTIES: 1. Assign accurate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes in accordance with official coding guidelines, payer requirements, and regulatory standards. 2. Review inpatient, outpatient, observation, surgical, and ancillary records for accurate code assignment. Ensure compliance with CMS, Joint Commission, OIG, AHIMA, and AHA coding standards. 3. Monitor daily workflows and unbilled account reports to reduce accounts receivable days for inpatient/outpatient accounts. 4. Review coded records to ensure accuracy, completeness, and consistency providing training or education to co-workers. 5. Stay current on coding updates, regulatory changes, and reimbursement methodologies. Serve as a resource for complex coding, reimbursement, and documentation questions. 6. Collaborate with CDI specialists and providers as needed to improve documentation quality and coding accuracy. 7. Assist with physician education regarding coding and documentation requirements. 8. Review clinical documentation for completeness, specificity, and regulatory compliance. 9. Work closely with Patient Financial Services, Revenue Integrity, and Compliance departments to optimize reimbursement. 10. Assist with charge capture reviews and coding-related revenue integrity initiatives. 11. Support external audits, payer reviews, and regulatory inquiries. 12. Participate in coding quality reviews and audit activities. Assist with identifying trends related to coding accuracy, denials, and documentation opportunities. 13. Support departmental and organizational performance improvement projects. Contribute to coding education and process improvement initiatives. 14. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association, and maintains current certifications as appropriate. REQUIRED STAFF COMPETENCIES: Demonstrates support for organizational and departmental mission. Supports and demonstrates knowledge of the Strategic Plan and the Hospital Key Initiatives. Fosters and promotes teamwork within department and the organization as a whole. Works to resolves conflicts constructively and in a timely manner. Ability to communicate effectively and simply with every customer and co-worker. Ability to display a positive, courteous and friendly attitude toward all contacts. Ability to build good relationships with others based upon a sustained effort of mutual support toward common goals. Ability to exercise good judgment, reasoning and concentration to detail and to take personal accountability for all actions in carrying out job duties. Is customer focused and committed to Quality and Process Improvement with a strong desire to provide service excellence. Possesses and displays a strong knowledge and understanding of the standards of practice for their position including, if and when applicable, commensurate computer skills; population specific and general competencies; organizational skills, time and project management. Possesses a vigorous and enthusiastic desire to learn and to grow both personally and professionally, and to improve one's skills in order to deliver the best possible care for our customers. Performs other duties as assigned. WORKING CONDITIONS: 1. Hospital and/or remote coding environment. 2. May require occasional attendance at meetings, educational sessions, and audits. 3. Generally sedentary position.