K.A. Recruiting

Coder & Clinical Documentation Manager - RHIA (relocation assistance)

Lincoln, NE 68506

Job Type: Other Allied Healthcare Opportunities Job Number: KRISTINC04

 Coder & Clinical Documentation Manager:

The position oversees 17 people, most of who are offsite coders but also an onsite Clinical Documentation Specialist. Relocation Assistance is offered for the right candidate. 


The Coding & Clinical Documentation Manager is responsible for accurate and timely clinical coding, DRG and APC assignments; adequate clinical documentation to support coding and grouping; education of organizational personnel including physicians regarding opportunities for improvement; and the efficient operation of coding and documentation functions. 



Registered Health Information Administrator (RHIA) required.  Bachelor's Degree in Health Information Management preferred.  Certified Coding Specialist (CCS) required.  Minimum of two (2) years of coding experience in an acute care setting required.  Prior supervisory or management experience desired.



  1. *Responsible for the personnel management functions (hiring, training, evaluating and supervising) for all Coding Specialists, Documentation Specialists.
  2. *Assures staff has adequate training in ICD-10-CM, CPT and HCPCS Level II coding guidelines, proper diagnoses and procedure code selection, documentation guidelines, abstracting of clinical data and present-on-admission indicators as well as Medicare reimbursement.
  3. *Performs or oversees quality reviews on inpatient and outpatient encounters to validate the ICD-10-CM, CPT and HCPCS Level II code assignments, APC and DRG groupings, missed secondary diagnoses and procedures, and also to ensure compliance with internal and external coding guidelines.
  4. *Develops and manages a clinical documentation improvement program that assures the quality of physician documentation and provides training/follow-up to correct incomplete or inconsistent documentation.
  5. *Works closely with Patient Financial Services personnel on procedure coding; provides expertise in  procedure coding.
  6. Collects and prepares data for specialized studies.
  7. Assists the Compliance Audit Committee with coding and documentation audits.
  8. Serves as an active member or leader of organization-wide related committees and teams.
  9. *Leads the Coding Section, HIM department and organization in new reimbursement methodologies and related computer applications.
  10. *Manages the procedural portion of the Charge Master and educates ancillary departments when needed.
  11. *Establishes ongoing rapport with physicians regarding documentation questions.
  12. *Maintains current knowledge of coding regulations and interpretations and communicates updates and changes to appropriate staff throughout the organization.
  13. Monitors unbilled reports for outstanding and uncoded encounters that need to be completed.
  14. Performs other related duties as assigned.



  1. Knowledge of HIM coding practices, regulations and processes.
  2. Knowledge of Medicare, Medicaid and third party reimbursement systems applicable to hospitals.
  3. Knowledge of computer hardware equipment and software applications relevant to work functions.
  4. Skill in conflict diffusion and resolution.
  5. Skill in coaching and educating coworkers and physicians.
  6. Ability to utilize critical thinking to analyze problems, identify needs and priorities and implement effective work strategies.
  7. Ability to establish and maintain effective working relationships with all levels of personnel, medical staff, ancillary departments and volunteers.
  8. Ability to communicate effectively both verbally and in writing.
  9. Ability to maintain confidentiality relevant to sensitive information.
  10. Ability to develop written procedures, communication documents and performance evaluations with measurable behaviors.
  11. Ability to schedule, direct, counsel and evaluate employee work and performance.
  12. Ability to lead multi-disciplinary teams and work as a team member.


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