Description
Coding Services assigns ICD-10-CM and ICD-10-PCS diagnosis and procedural codes to inpatient medical records to ensure accurate reimbursement, regulatory compliance, and comprehensive clinical data integrity across The Ohio State University Health System.
The department ensures that coded data accurately reflects patient acuity, severity of illness (SOI), and risk of mortality (ROM), directly influencing MS-DRG and APR-DRG assignment, Observed-to-Expected (O:E) Mortality, Vizient benchmarking performance, publicly reported quality outcomes, and enterprise analytics.
Coding Services serves as a steward of enterprise clinical data, supporting hospital financial stability, regulatory reporting, research initiatives, strategic planning, performance benchmarking, and quality improvement efforts within a high-acuity academic medical center environment.
In collaboration with Clinical Documentation Integrity (CDI), Revenue Cycle, Quality, Compliance, and clinical leadership, Coding Services proactively identifies documentation and coding trends that contribute to denials, underpayments, compliance risk, and operational inefficiencies. The department partners across disciplines to implement root cause–based corrective actions that strengthen data accuracy and revenue integrity.
Advanced technologies, including Computer Assisted Coding (CAC), encoder platforms, and system automation tools, are leveraged to enhance efficiency, accuracy, audit readiness, and continuous process innovation while maintaining adherence to Official Coding Guidelines, CMS regulations, payer-specific requirements, and federal and state reporting standards.
Position Summary
The Senior Medical Records Coding Specialist is responsible for the timely, accurate, and compliant coding of inpatient medical records following discharge. This role requires advanced expertise across multiple inpatient service lines and complex clinical specialties typical of a tertiary and quaternary academic medical center, including high-acuity medical and surgical cases.
Primary responsibilities include:
- Selecting and sequencing the appropriate admitting diagnosis, principal diagnosis, and secondary diagnoses
- Identifying and sequencing principal and secondary procedures
- Assigning accurate ICD-10-CM and ICD-10-PCS codes in accordance with Official Coding Guidelines
- Abstracting required demographic and clinical data elements, including admission source, admission type, discharge disposition, and attending and procedural providers
- Ensuring accurate MS-DRG and APR-DRG assignment reflective of documented severity and complexity
Coding is performed utilizing Computer Assisted Coding (CAC) and encoder software following comprehensive review of documentation within the IHIS electronic medical record system. Abstracted and coded information interfaces directly with the IHIS Resolute Billing system to support compliant billing and reimbursement.
The Senior Coding Specialist is responsible for resolving all coding edits and validation checks to ensure complete and accurate code assignment, optimal DRG integrity, and audit readiness. This role contributes to hospital quality outcomes by ensuring documentation and coding accurately capture patient acuity, SOI/ROM, and clinical complexity.
In addition, the role:
- Maintains departmental productivity and quality standards
- Adheres to approved work schedules and submits required volume logs
- Actively participates in denials prevention efforts through education, trend identification, and collaboration with CDI and Revenue Integrity teams
- Supports compliance initiatives and maintains readiness for internal and external audits
- Engages in ongoing professional development and continuous improvement initiatives to support innovation and operational excellence
Minimum Required Qualifications
Associate’s Degree in Health Information Management. Credentialed as a Registered Health Information Technician, Registered Health Information Administrator, or Certified Coding Specialist by the American Health Information Management Association. 2 years of relevant experience required. 4-6 years of relevant experience preferred.
Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post offer process.
Applicant Location
US residents only