Job Title:
Med Records Coding Spec - Lead
Job ID:
Shared Services
Full/Part Time:
FTE %:
Salary Range Min:
Salary Range Max:

Position summary

Med Records Coding Spec - Lead (Job Opening 442449) - Scope of Position Coding services assigns diagnosis and procedural codes to inpatient and outpatient medical records to facilitate the reimbursement and data collection for the individual business units of the OSU Health System. ICD-9-CM and ICD-10-CM/PCS diagnoses and procedure codes are applied to inpatients and CPT-4 procedure codes are applied to all outpatients treated within the OSU Health System that are not captured through the charge description master. Medical record abstract data is assigned based on information reviewed for accuracy in IHIS during the coding process. This position is responsible for training medical record coding specialists and coding some or all the following types of records: inpatient, emergency department, ambulatory surgery, Talbot, outpatient clinic, pain block and ancillary areas. The Lead Medical Records Coding Specialist will also participate in hospital?s trauma registry. Position Summary The position is responsible for training and supporting new medical record coding specialists. The Lead Coder responsibilities also include auditing the coding of records, assuring inpatient and outpatient coding policies and procedures reflect practice, ensuring the integrity of information in the electronic medical record, and monitoring completion of coding activities. This position also codes medical records and other documents at the conclusion of the patient?s visit. This requires selection of appropriate admitting diagnosis, principal and secondary diagnoses, principal procedure and secondary procedures; assigning accurate ICD-9, ICD-10 and/or CPT-4 codes; sequencing the diagnoses and procedures codes; and abstracting information including admission source, type, disposition, admitting, attending and procedure attending physicians. Codes are selected in the Encoder Software following review of information in the electronic medical record system, IHIS. Information abstracted and coded is interfaced to IHIS Resolute Billing system. This staff member is responsible to address all edits during the coding and abstracting process for complete and accurate coding and MS-DRG and APR-DRG assignment for hospital reimbursement. This staff member will maintain productivity and quality standards set for the department maintain an approved work schedule and submit a weekly volume log. The Lead Coder may also provide area coverage in the absence of a manager.

Education and experience

? Associate Degree in Health Information Management or other qualifying associate degree in health care OR ? Minimum two years of daily hospital coding production specific to the area of discipline (i.e. inpatient coding or outpatient coding). Generally, lead medical records coding specialists are inpatient or outpatient coders promoted from the medical records coding specialist role or senior medical records coding specialist role at OSUWMC. AND ? Accredited as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) by the American Health Information Management Association, or Certified Outpatient Coder (COC) by AAPC or CPC with CHONC AND ? Minimum of two years academic medical coding experience. o Inpatient: service lines such as cancer, transplant, obstetrics, rehabilitation and cardiology. o Outpatient: emergency, observation, outpatient, ASU and James series.