University of Rochester Lead Medical Records Coder in Rochester, New York


Full Time 40 hours Grade 010 Health Information Mgmt Dept




General Purpose:

Manage the inpatient/outpatient/Emergency Department area in the activities of auditing of coding for all affiliates. Responsible for the supervision of home health care coding staff engaged in the collection and classification of health information data for uses of patient care, reimbursement, financial, education, quality, utilization management, clinical documentation and research purposes. Manage the auditing process for all coding areas, including affiliates, assuring that HIM coding is meeting or exceeding all state, federal, compliance standards for all affiliates. Coordinates all new coding staff orientation and training to assure properly trained coding staff.

Typical Duties:

Oversee Home Health Care coding staff to ensure timely and accurate classification and abstracting of home health care coding. Responsible for analysis of deficient medical record documentation according to Joint Commission, Federal and New York State regulations and hospital policy.

Perform supervisory duties, including scheduling employee time off and verifying employee’s work time. Meet with new staff weekly to ensure successful onboarding of the staff. Assume responsibility of Manager or Lead Coder as appropriate.

Develop and implement in-depth training programs for Senior Medical Record Coders/Record Completion/Coding Workflow staffing for all affiliates in conjunction with Compliance and appropriate external agencies/resources to meet all departmental goals.

Creates and updates presentations/webinars to educate and train HIM coders coding and coding updates. Provides education to ensure compliance of coding either to an individual or to a team. Prepares orientation materials and orients new hires on coding training, encoder usage, system usage, etc.

Performs internal audits of coding to determine compliance with coding policies and procedures annually and on an ad hoc basis. Conducts in-depth reviews of medical record chart documentation to ensure compliance with coding clinics and guidelines. Coordinates yearly or more often coders’ audits to ensure compliance.

Recruit, interview, hire, evaluate performance, enforce personnel policies and guidelines, counsel staff on performance issues, develop performance improvement plans, implement disciplinary actions and perform other related personnel functions for more than ten employees in conjunction with Coding Manager. Perform 90 day and annual performance evaluations.

Receive and interpret American Hospital Association coding guidelines for department and hospital. Act as definitive coding authority and resource for all hospital coding quality issues, providing guidance on coding to hospital departments (Finance, Patient Accounts, Utilization Review, Office of Clinical Practice Evaluation, Directors’ Office, etc.). Act as definitive coding authority and resource for all hospital coding quality issues, providing guidance on coding to hospital departments (Finance, Patient Accounts, Utilization Review, Administration and all affiliates).

Participate, test, train staff on new or updated system updates, or implementation for any new or existing service line or processes that relate to coding throughout the health system.

Receive and interpret Coding Clinic, Inpatient Prospective Payment System and Outpatient Prospective Payment System guidelines for department and hospitals.

Attend other departmental, hospital and professional meetings to keep knowledge current regarding hospital, Joint Commission, governmental and third party payer regulatory and procedural changes. Communicate information to staff. Participate or conduct area staff meetings to share information and discuss work plans and resolution of problems.

Prepares and coordinates coding education presentations for all coders/finance/UM/Quality and affiliate coders as it relates to Inpatient Prospective Payment System (IPPS) annually and Outpatient Prospective Payment System (OPPS) annually or as needed.

Coordinates any external audit functions as it pertains to coding.


Associate’s degree in Health Information Management, 3 years previous inpatient/outpatient/Emergency Department coding/auditing and DRG/APC/AGG assignment experience, preferably in a tertiary care facility or equivalent combination of education and experience.

Credentialed by the American Health Information Management Association as Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) preferred.

Preferred Qualifications:

Extensive and in-depth knowledge of ICD-10 and CPT coding classifications including coding conventions and guidelines, DRG/APC/APG and reimbursement methodology as well as regulatory requirements of government and third party payors relating to coding and prospective payment. Auditing experience preferred. Experience with PC and mainframe computer systems.

Ability to problem solve and work independently.

Excellent verbal and written communication skills.

Ability to prepare and compile statistical reports.

Ability to work with and communicate with both on campus and remote coder.

Must be able to attain goals set by the hospital and department to keep workloads at acceptable levels.

EOE Minorities/Females/Protected Veterans/Disabled

Job Title: Lead Medical Records Coder

Location: Strong Memorial Hospital

Job ID: 207707

Regular/Temporary: Regular

Full/Part Time: Full-Time