Lead Medical Coder

Lead Medical Coder

The Lead Medical Coder serves as a certified professional coder and assists the Medical Coding Office Manager with oversight of daily coding operations. Performs the full range of coding, assigns ICD, CPT, HCPCS, and medical inpatient codes; abstracts data from the record; performs chart analysis, research coding issues; peer reviews; and serves as a medical documentation and coding technical expert to TONHC providers.

Scope of Work: This position is located within Tohono O'odham Nation Health Care (TONHC). The work involves performing specialized medical record tasks and resolving problems using established processes, coding conventions, and guidelines. Performance of duties reflects directly on patient care by recording services performed on the patient. The incumbent works independently under the general supervision of the Supervisor or designee.

Essential Duties and Responsibilities: (Depending on the area of assignment, an incumbent may not be required to perform some of the duties listed below):

• Assists with the leadership and guidance to the day-to-day inpatient and outpatient medical coding service and staff.
• Assigns codes to diagnosis and procedures using ICD (International Classification of Diseases), HCPCS (Healthcare Common Procedure Coding System), and CPT (Current Procedural Terminology) codes.
• May be assigned to medical inpatient coding; reviews physician's patient medical documentation and determines the most appropriate corresponding code.
• Performs the full range of coding per current ICD coding conventions and the official coding guidelines under Federal, State, and Cooperating Parties.
• Ensures codes are accurate and sequenced correctly per government and insurance regulations.
• Reviews Electronic Health Record (EHR) data and ensures providers and other clinicians assign the appropriate ICD codes; follows up with the provider on insufficient or unclear documentation.
• Assigns the appropriate CPT code for all outpatient medical, surgical, non-physician professional services, and diagnostic services.
• Utilizes the CPT Assistant or other coding software to assist in the proper use of codes.
• Observes the coding rules established by AMA (American Medical Association).
• Assigns the appropriate HCPCS code for items, supplies, and non-physician services used in reimbursement claims processing.
• Appropriately assigns modifiers to codes and verifies site, unit number, and location of services based on the documentation of the record.
• Assigns and reports codes clearly and consistently supported by physician documentation in the health record.
• Assists and educates physicians and other clinicians in proper documentation practices, further specificity, sequencing, or inclusion of diagnoses or procedures to reflect acuity, severity, and other events.
• Establishes a working relationship with providers; consults physicians and other clinicians for clarification and additional documentation before code assignment when necessary.
• Work with computerized information systems, including an electronic health record, encoding software, the internet, and other software applications.
• Maintains and enhances coding skills, stays abreast of changes in codes, coding guidelines, and regulations.
• Abstracts and enters all data for coding, billing, GPRA indicators and CMS, The Joint Commission (TJC), and the governmental reporting process.
• Abstracts and enters all data into a computer system for statistical purposes, third-party billing, and continuity of patient care.
• Provide analysis of documentation and coding issues regarding areas of concern of the health record, including lack of documentation, legibility, system issues, EHR, and other matters.
• Assists with the formulation of query forms and formats for providers to be used for clarification and documentation.
• Identifies inconsistencies within the medical record and participates in QA functions and peer reviews.
• Participates in developing hospital and health centers coding policies and ensuring coding policies complement the official rules and guidelines.
• Assist with technical issues within the computer systems, including the EHR.
• Assist in maintaining and updating the ADT and PCC software packages.
• Provides expertise and support in EHR development and maintenance of charge lists, pick lists, templates, and subject matter experts.
• Monitors and reports any discrepancies in the EHR in regards to proper code assignments.
• Ensures the quality of data in information systems by conducting audits and continuously analyzing the data.
• Attends meetings and serves as a resource person for coding.
• Assists with coding and training of coworkers, providers, contractors, student interns, and other employees.
• Serves as a resource for PCC data entry staff, assisting with coding, EHR; and, documentation issues.
• Contributes to a team effort and performs other job-related duties as assigned

Knowledge, Skills, and Abilities:

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Knowledge of applicable federal, state, tribal laws, regulations, and requirements.
• Knowledge of computer software, including word processing, database, and spreadsheet application.
• Knowledge of legal regulations and requirements on confidentiality, specifically to the Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Knowledge of and skill in applying a comprehensive body of rules, procedures, and operations, such as health information management, medical records activities, and computerized data entry and retrieval systems.
• Knowledge of official coding conventions and guidelines established by the AHIMA, AHA, CMS, NCHS, etc.
• Knowledge of ICD/CM (International Classification of Diseases/Clinical Modification), and HCPCS (Healthcare Common Procedure Coding System), CPT (Current Procedural Terminology) appropriate Level coding.
• Knowledge and understanding of Diagnostic Related Group (DRG) and Ambulatory Patient Classification (APC) systems and associated encoding software applications.
• Ability to abide by and promote compliance with the AHIMA Standards of Ethical Coding and with the Compliance Plan and Coding Compliance Plan of the TONHC Hospital and Clinics; and the Internal Control Policy of IHS.
• Knowledge of the healthcare industry pertains to the functions of the position, capacity, and willingness to obtain continuing education required to maintain certification and stay apprised of changes in coding and the health care industry.
• Knowledge of pharmacology, including the ability to reference the Physician's Desk Reference (PDR).
• Knowledge of the RPMS software program, specifically the PCC, ADT, Scheduling, and EHR applications.
• Knowledge and ability to use computers, scanners, and reference materials for day-to-day tasks within the hospital.
• Knowledge of and ability to conduct chart reviews and coding audits to ensure accuracy and appropriate coding and compliance with rules and regulations.
• Ability to use standardized computer software such as spreadsheets, word processors, electronic email systems, and database software programs.
• Skill and commitment to accuracy and detail.
• Skill in providing superior customer service to external and internal customers.
• Skill in operating various word-processing, spreadsheets, and database software programs.
• Skill in organizational and office technology.
• Ability to communicate effectively with others, orally and written.
• Ability to prepare reports in a well-written, concise format using applicable software applications.
• Ability to generate reports and analyze data from these systems.
• Ability to establish performance improvement functions, track and report outcomes and conclusions or follow up orally and in writing.
• Ability to organize and plan work.
• Ability to deal with individuals from a variety of diverse backgrounds.
• Ability to work independently, use sound judgment, and meet deadlines.
• Ability to provide accurate reports.

Minimum Qualifications:

• High School Diploma or General Education Diploma.
• Three years of work experience in medical coding or billing.
• Six months supervisory or leadership work experience in an office setting.

Licenses, Certifications, Special Requirements:

• Must possess and maintain certification as a Certified Coder certificate from the American Academy of Professional Coders or the American Health Information Management Association, or equivalent.
• Must type 40 WPM.
• Upon recommendation for hire, a criminal background and a National FBI fingerprint check are required to determine suitability for employment, including a 39-month driving record.
• May require possessing and maintaining a valid driver's license (no DUIs or major traffic citations within the last three years).
• If required, must meet the Tohono O'odham Nation tribal employer's insurance requirements to receive a driver's permit to operate program vehicles.
• Based on the department's needs, incumbents