• Reviews complete inpatient medical records, including physician notes, operative reports, consultations, imaging, lab results, and discharge summaries • Assigns and properly sequences accurate ICD-10-CM diagnosis and ICD-10-PCS procedure codes in accordance with Official Coding Guidelines, UHDDS definitions, Coding Clinic guidance, and CMS to a full range of inpatient services including cases with a high complexity level • Assigns correct and optimal DRGs (MS-DRG/APR-DRG) • Ensures accurate capture of Major Comorbid Conditions (MCC)/Comorbid Conditions (CC), Present on Admission (POA) indicators, Hospital-Acquired Conditions (HACs), Patient Safety Indicators (PSIs), Severity of Illness (SOI), and Risk of Mortality (ROM) • Issues compliant physician queries when documentation is incomplete, ambiguous, or inconsistent • Identifies documentation gaps and escalates when clarification is needed • Resolves coding edits, queries, and discrepancies in a timely and compliant manner • Participates in internal and external audits; assists in implementing corrective action plans • Collaborates with Clinical Documentation Improvement (CDI) to ensure complete documentation and optimal DRG assignment • Supports coding leadership by identifying documentation improvement opportunities and workflow challenges • Meets or exceeds departmental accuracy and productivity standards • Codes inpatient encounters efficiently to support timely billing and reduce DNFB • Assists with reviewing accounts held for coding-related issues • Maintains required coding credentials (CCS, RHIT, RHIA) • Stays current with all annual ICD-10-CM/PCS updates, DRG changes, and regulatory updates • Participates in continuing education, team meetings, and training sessions • Adapts to changing department demands required to maintain a high level of performance • Performs other duties as assigned

• Responsible for entering/auditing/coding patient services to ensure encounters transfer properly for submission to insurance payers. • Analyze coding related claim issues, process gaps and denials to trend feedback for providers by location and/or specialty. • Review provider documentation (including hospital procedures) and translate services into correct codes. • Append payer specific modifiers and claim criteria when applicable. • Review incomplete encounters and code based on available documentation in EHR systems. • Know and understand several different coding systems, including ICD-10-CM, ICD-10-PCS, CPT, Level 1 HCPCS and Level 2 HCPCS. • Use computers / billing software to create and bill encounters that generate clean claims. • Attend internal meetings relevant to EHR workflows and share best coding practices. • Assist Operations when coding guidance is requested for existing or new services. • Understand payer reimbursement and PPS visit qualification for Medicare and Medicaid. • Trend areas of focus where provider training or re-training is needed. • Monitor, trend and resolve tasks related to coding edits, rejections, and denials. • Communicate with providers, patients, and insurance payers. • Review patient accounts and correct any missing or inaccurate information. • Investigate and appeal claims that were denied incorrectly. • Complete coding projects such as quarterly or ad hoc provider chart audits. • Adapt to updates and changes in billing software. • Perform all other duties and tasks as assigned.

• You will code hospital and professional inpatient visits using the International Classification of Disease 10-Clinical Modification (ICD-10-CM) and Current Procedure Terminology (CPT) coding methodology in accordance with official coding and reimbursement guidelines • You will work under the general supervision and reporting to the Director of HIM • You are responsible for professional CPT coding for Medicare and Medicare like payers • You will abstract all data elements into the WellSky EMR platform • You will use the TruBridge encoder integration to review Medical Necessity edits and CCs, MCCs, coding order and DRG assignment • You will maintain current working knowledge with all coding rules, coding guidelines, Medicare, and Medicare like payer regulations in accordance with the hospital coding compliance policies and procedures

• Provides direct supervision, mentorship, and daily operational oversight of the Lead Certified Professional Coder and coding staff • Supports staffing, scheduling, workload distribution, and productivity management • Assists with onboarding, training, coaching, and performance evaluations of coding staff • Promotes accountability, collaboration, and professional development within the team • Performs and oversees charge review to determine appropriate CPT and ICD-10 codes for physician services • Ensures compliance with CMS, regulatory, and third-party payer guidelines