Responsible for assuring coding is being performed accurately. Is responsible for assessing coding accuracy and completeness of inpatient and outpatient medical record documentation by conducting random and focused coding audits; documenting, preparation and timely presentation of audit results. Educates individuals on the rules/regulations associated with coding. Functions as lead coding advisor to Coding Specialists and answers all educational questions timely. Functions as Lead Coding Advisor to assigned HIS Coding Specialists.

Essential Functions

• Performs, training and quality monitoring of new, established employees and students.
• Responsible for providing timely feedback on the application of coding guidelines, practices, and proper documentation techniques and data quality improvements.
• Performs random coding quality review on monthly basis and provides timely feedback, additional training and education as needed.
• Identifies and trends areas of opportunity for performance improvement for all coders and provides appropriate feedback to management.
• Demonstrates comprehensive understanding of CCs/MCCs, impact on quality reporting, UHDDS guidelines, HACs and PSIs.
• Assists with the analysis of case mix reports and other statistical reports.
• Demonstrates comprehensive understanding of APG, EAPG and LCDNCD and CCI regulatory edits.
• Responsible for researching errors related to coding or missed documentation from the medical record in order to provide accurate coding guidance to support established processes.
• Assists with the facilitation of scheduled external audits.
• Responsible for designing, implementing, and managing ongoing Departmental monitoring activities and educational programs to ensure proper coding and compliance with all regulatory statutes.
• Performs targeted second level reviews.
• Maintains up to date credentials. Maintains updated knowledge of regulatory guidelines and regulations affecting the coding field. Maintains knowledge of guidelines and regulations affecting the UHHS Coding Department.

Additional Responsibilities

• Assists when needed, with abstracting Medical Records to identify, sequence, and code diagnostic and procedural information timely and accurately.
• Participates in educational and informational activities.
• Participates in student mentorship programs.

Required For All Jobs

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.