Accounts for coding and abstracting of patient encounters, including diagnostic and procedural information, significant reportable elements and complications. Researches and analyzes data needs for reimbursement. Analyzes medical record and identifies documentation deficiencies. Serves as resource and subject matter expert to other coding staff.

• Reviews and verifies documentation supports diagnoses, procedures and treatment results. Identifies diagnostic and procedural information.


• Audits clinical documentation and coded data to validate documentation supports services rendered for reimbursement and reporting purposes.


• Assigns codes for reimbursements, research and compliance with regulatory requirements utilizing guidelines. Follows coding conventions. Serves as coding consultant to care providers.


• Identifies discrepancies, potential quality of care, and billing issues. Researches, analyzes, recommends and facilitates plan of action to correct discrepancies and prevent future coding errors. Identifies reportable elements, complications and other procedures.


• Serves as resource and subject matter expert to other coding staff. Assists lead or supervisor in orienting, training, and mentoring staff. Provides ongoing training to staff as needed. Handles special projects as requested.