• Reviews the content of the medical record for hospital and professional inpatient or outpatient records. • Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records. • Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form using procedure codes as required. • Using the Encoder software program, determines the codes for all diagnoses and procedures. • Determines their sequencing to legally maximize reimbursement. • Assigns the appropriate DRG. • Assigns codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant or other standard coding guidelines. • Queries physicians as needed to clarify documentation within the patient’s record to facilitate complete and accurate coding. • Assists the Coding Quality and Professional Manager with training of new coding staff.