Lead Coder

Location: Winchester, MA
Job ID: 158154-1A
Date Posted: Jun 20, 2022
Category: Support

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Job Description

Welcome To

Welcome to Winchester Hospital, part of Beth Israel Lahey Health. Winchester Hospital was the first hospital in Massachusetts to earn Magnet recognition, the American Nurses Association’s highest honor for nursing excellence, three times. It has since received the recognition a fourth time. As the northwest suburban Boston area’s leading provider of comprehensive health care services, the 229-bed facility provides care in general, bariatric and vascular surgery, orthopedics, pediatrics, cardiology, pulmonary medicine, oncology, gastroenterology, rehabilitation, radiation oncology, pain management, obstetrics/gynecology and a Level IIB Special Care Nursery.


About the Job

Contributes to the Hospital’s mission by performing the dual role of lead and Coder.  This hands-on position oversees daily coding operations, troubleshooting issues to maximize the team’s efficiency and accuracy and develops and promotes collaborations within HIM, with Patient Financial Services and with Physicians.  Also functions at a Coder III level reviewing physician orders on inpatient to interpret the medical notes and assign the appropriate multilevel ICD codes.  This specialized administrative support position impacts the hospital’s financial success by streamlining reimbursement and physician satisfaction by minimizing the need to involve physicians in the reimbursement process. This position will also impact employee satisfaction by ensuring the coding team operates like that of an employer of choice.





·         High School Diploma or equivalent

·         6 years general ICD 9 or 10 diagnosis and procedure coding experience which includes multi-level coding or three years of inpatient coding experience.

·         Computer experience

·        Meditech or experience with other electronic medical records



·        Associates degree in Medical Records

·        Experience in Health Information Management

Other Skills/Knowledge:


·        Demonstrated ability to lead

·        Excellent communication and customer service skills

·        Strong knowledge of CPT coding

·        Knowledge of medical terminology including anatomy and physiology, clinical medical surgery, diagnostic tests, radiology, pathology, pharmacology, and various medical specialties.

·        For safety and quality reasons, must be able to read, write and communicate effectively in English with patients, visitors and fellow members of the hospital team.

Preferred: Trained in ICD10 coding. 


Required:  Certified Coding Specialist (CCS), Registered Health Information Administrator or Registered Health Information Technician


Professional Commitment Requirements:  Keep abreast of developments in the field and/or licensure through continuing education, participation in professional organizations or a combination of both.

On-call:  N/A

Schedule requirements:  Generally business hours, based on business needs.

Travel requirements:   N/A. 



·        Reports to the Coding Manager.

·        Directs the work of others; does not supervise others. 

As part of the HIM team, this position performs the following functions in accordance with Hospital procedures and industry standards and regulation:



  • Oversees shift operations, assigning functions to optimize efficiency, ensuring staff are operating within their job expectations.   

  • Works collaboratively with the manager in the planning and implementing of operations and performance improvement initiatives for the areas of responsibility and the department as a whole. 

  • In the absence of the manager, the Lead will assume the supervisory role and make decisions that will impact coding and departmental operations to ensure that the workflow runs smoothly to ensure that the cash flow to the hospital is continuous and there is no backlog in Accounts Receivables.

  • Demonstrates technical expertise in the assigned area and fosters a climate of compliance and professional excellence.

  • Troubleshoots operational issues and customer service calls and complaints.  Follows the proper chain of command to resolve concerns, addressing the short term issue and recommending and/or working towards long-term resolution and improvements with HIM leadership team.

  • Provides performance feedback on staff directly to the staff member thus fostering a culture of continuous learning and improvement and to the manager as appropriate.  Addresses staff safety concerns promptly. Gives input into the performance evaluation process.

  • Precepts and mentors staff so to expand their knowledge and competence in coding operations and processes.

  • Builds and maintains a staffing plan in the scheduling system that is fair, efficient and fiscally prudent.  Reviews vacation requests and recommends request approvals and coverage plan to the Manager.

·        Assist the manager with green sheets and Report Express.


Coder III

·        Reviews complex medical records on inpatient procedures and tests utilizing advanced knowledge of ICD codings, assigns and inputs the appropriate multi-level diagnosis and procedure code for inpatient patients stays.

·        Data inputs other pertinent clinical information as necessary and appropriate.

·        Keeps abreast of various insurance plan submission requirements and inputs coding to meet those requirements.

·        Keeps abreast of the industry/field ethical coding guidelines and consistently adheres to those standards.

·        Verifies batch carries over properly to billing system.  Reviews and addresses rejects. 

·        When necessary follows up with the physician/provider for clarification

·        Investigates claim denials, collaborating with patient financial services and as necessary involving the physician/provider.

·        Provides coverage for Coder I and II work including CPT coding.

·        Provides technical guidance and assistance to Coder Is and Coder IIs.

·        Participates in quality and other audits as requested.


Full Time, 40 hours.

About Us

Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.