• Assign accurate ICD-9-CM, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on clinical documentation.

• Validate that final diagnoses and operative procedures documented by physicians are complete and accurately coded.

• Abstract relevant information from health records to identify secondary diagnoses, complications, and co-morbidities.

• Review medical records for documentation consistency, completeness, and adequacy.

• Ensure the final diagnosis reflects the care and treatment provided and assign the correct DRG for all inpatient cases.

• Provide training, guidance, and mentorship to Medical Coders and Medical Records Technicians on coding practices and regulatory updates.

• Analyze physicians' documentation to ensure accurate assignment of Evaluation & Management (E&M) levels using the appropriate CPT codes.

• Ensure compliance with DOH (formerly HAAD) coding guidelines, regulations, and coding standards.

• Provide constructive feedback to physicians regarding coding discrepancies, documentation gaps, and missed coding opportunities.

Desired Candidate Profile

• Bachelor's Degree in Allied Health Sciences or a related field.

• Minimum 2 years of medical coding experience.

• Valid Certified Coding Associate (CCA) certification from AHIMA or Certified Professional Coder (CPC) certification from AAPC.

• Proficient in MS Office and general computer applications.

• Excellent written and verbal communication skills in English.

Competencies

• Achieve assigned objectives in line with organizational and stakeholder expectations.

• Demonstrate professionalism and collaborate effectively with multidisciplinary teams.

• Manage multiple tasks efficiently, adapt to changing priorities, and meet deadlines.

• Willingness to attend meetings outside normal working hours when required.