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Lead Coder (Internal Position)

Company: Good Shepherd Hospice
Location: Melville
Posted on: June 6, 2021

Job Description:

Lead Coder (Internal Position)

Facility: CHS Services Inc Location: Melville, NY Department: HIM EMPI DRG Appeals Category: Administrative / Business Support Schedule: Full Time Shift: Day shift ReqNum: 6034470 Internal Position

At Catholic Health, our primary focus is the way we treat and serve our communities. We work collaboratively to provide compassionate care and utilize evidence based practice to improve outcomes to every patient, every time. We are committed to caring for Long Island. Be a part of our team of healthcare heroes. Catholic Health is also proud to be voted one of Newsday's Top Places to Work on Long Island in 2018 and 2019 and Modern Healthcare's Best Place to work in both 2019 and 2020.

Position Summary:

The lead coder is responsible for performing all the duties of a coder including performing a thorough review of each medical record, identifying all relevant, sufficiently documented, and clinically supported conditions, and accurately assigning ICD 10-CM, ICD 10- PCS and/or CPT codes for all applicable diagnoses and procedures in accordance to coding guidelines. The lead coder must have exceptional knowledge of coding guidelines and be skilled in coding an extensive variety of charts with a high rate of accuracy. The lead coder must possess strong leadership skills and will assist the Coding Leadership team with developing and providing education and training to staff. The lead coder will assist with training new hires. The lead coder will participate in auditing charts for coding quality and will calculate and report accuracy rates to the management team.


  • Thoroughly read and interpret the documentation contained in every medical record to identify all diagnoses and procedures to which codes must be affixed.
  • Assess the adequacy of documentation to ensure that it supports the principle diagnosis, principle procedure, complications and comorbid conditions assigned codes.
  • Demonstrates a strong familiarity of diagnostic and procedural terminology.
  • Ability to apply knowledge of disease processes and to index medical terms/procedures to the appropriate class in the classification system.
  • Apply knowledge of ICD-10-CM and ICD-10-PCS instructional notations and conventions to facilitate location of the correct code (s) for each episode of care.
  • Facilitate comprehensive retrieval by recognizing when more than one code is required to adequately code a given condition.
  • Apply knowledge of ICD-10-CM and ICD-10-PCS coding principles to completely and correctly code episodes of patient care.
  • Enter and edit patient data for assigning DRG's in the Grouper, following approved guidelines for coding and sequencing.
  • Enter and edit patient data into computerized abstracting system for in-patients and outpatients as assigned.
  • Utilize accurate CPT codes for the procedural coding of outpatient charts
  • Follow all coding guidelines, rules and regulations when assigning codes.
  • Assist the Coding Leadership team with developing and providing education and training to staff.
  • Train and educate newly hired coders.
  • Audit coder's charts for coding quality, calculate and report accuracy rates to the management team.
  • Support the Coding Leadership team by monitoring the work queues and other assigned tasks as needed.

Minimum Requirements:

  • High School Diploma or GED required
  • CCS or CCS-P required
  • Minimum one year preferred experience with hospital ICD-10-CM and CPT Coding. A coding certificate from an approved program.
  • Works in collaboration with others by building team spirit.
  • Seeks opportunities to provide friendly & courteous service.
  • Works to the highest quality standards & ensures the safety of patients, self, and others.
  • Evaluates own work for opportunities to improve.
  • Proactive and takes responsibility for actions, projects and people.
  • Exemplifies and supports the Mission, Vision and Values of CHS in carrying out job responsibilities.

Learn More about this Location

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Keywords: Good Shepherd Hospice, New Haven , Lead Coder (Internal Position), Other , Melville, Connecticut

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