A Brief Overview
Responsible for assuring coding is being performed accurately. Is responsible for assessing coding accuracy and
completeness of Revenue Cycle coding process/policy and workflows for inpatient and outpatient medical record
documentation by conducting random and focused coding reviews; documenting, preparation and timely
presentation of results. Educates individuals on the rules/regulations associated with coding. Functions as lead
coding adviser to Coding Specialists and answers all educational questions timely. Functions as Lead Coding
Adviser to assigned HIS Coding Specialists.
What You Will Do
• Performs, training and quality monitoring of new, established employees and students.
• Responsible for providing timely feedback to the team 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 LCD\NCD and CCI regulatory edits.
• In support of continual improvement of the HIS Coding and CDI Teams, 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.
• Responsible for designing, implementing, and managing ongoing departmental improvement imitative by
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.
• Partners with the Internal Audit and the Compliance & Ethics Department on internal and external audits.
• Participates in educational and informational activities.
• Participates in student mentorship programs.
• 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.