Hospital Certified Senior Coder

Hospital Certified Senior Coder
Clinical Document-Coding Mgmt

The Hospital Certified Senior Coder will:

  • Utilizing judgment gained from coding experience, assign appropriate codes for all applicable diagnosis and procedures, concurrently on patient units.
  • Code and abstract.
  • Independently manage daily workflow on assigned unit(s).
  • Validate correct patient types (observation vs. inpatient) by checking physician order.
  • Reconcile HIM discharged not final billed report (DNFB) to ensure all discharged charts are accounted for on his/her assigned units.
  • Notify coding supervisor, director, clinical documentation; assistant manager HIM; nursing manager, and clinical documentation specialist covering unit regarding missing patient records.
  • On discharge reconcile with clinical documentation specialist nurse, finalize coding, abstract, accept final DRG for billing.
  • Deliver discharged charts to the Health Information Management Department.
  • Complete concurrent admission reviews within 48 hours of patient admission (excluding weekend and holidays).
  • Ensure timely follow-up reviews in accordance with unit review guidelines.
  • Collaborate with clinical documentation nursing specialists by identifying conflicting, ambiguous, or incomplete information in the medical record.
  • Participate in hospital performance improvement activities as requested.
  • Ensure that hospital acquired conditions (HAC), and complications are validated by clinical documentation nursing specialists, and/or performance improvement department.
  • Query physicians for all questions relating to diagnostic and procedural information in the medical record.
  • Notify coding supervisor all issues that will delay billing.

MENTORING and TRAINING: Under the direction of the Director and/or coding supervisor, Clinical Documentation & Coding Management:
  • Assist with training of newly hired coders to include, but not limited to CPT, HCPCS and/or ICD coding.
  • Train fellow coders on use of computer systems including, but not limited to, McKesson STAR and 3M.
  • Respond to questions and assists fellow coders with code assignments as needed.

  • Knowledge of coding systems, medical terminology, anatomy and physiology required.
  • A minimum of five (5) years of inpatient coding experience required.
  • Strong interpersonal and decision-making skills required.


In-Hospital Experience Required!

Grade 123