Job Description

Location: Steward Health Care
Posted Date: 8/25/2021


Conducts inpatient coding quality audits to validate code assignment is supported by clinical documentation in the medical record. Highly proficient in the proper assignment of ICD-10-CM and PCS codes.


  • Performs coding audits of a wide variety of complex inpatient records to validate the ICD-10-CM, PCS codes, MS-DRG and/or APR DRG assignments.
  • Provides written, detailed rationale and supporting evidence for recommendations on audit findings.
  • Delivers educational feedback to coding staff regarding audit findings.
  • Provides guidance to coding staff and management in identifying and resolving coding issues.
  • Identifies documentation improvement opportunities that impact coding accuracy.
  • Initiates physician queries for clarification of documentation in the medical record to achieve accurate code assignment.
  • Collaborates with the clinical documentation improvement team for conflicts between code assignments.
  • Reviews and researches billing edits.
  • Assists with DRG denials from payers including researching and writing appeal letters.
  • Ability to interpret Medicare and NCCI guidelines, National and Local Coverage Determinations to support coding compliance.
  • Maintains a minimum of 95% accuracy on all coding audits.
  • Maintains productivity standard of approximately 20 inpatient coding reviews per day.
  • Performs other duties as assigned including training/mentoring of new staff and performing research related to special projects


  • Comprehensive understanding of coding guidelines, Coding Clinics and appropriate coding references along with the ability to employ these coding resources to audit findings.
  • Excellent interpersonal verbal and written communication skills to accurately relay information to internal and external customers.
  • Excellent organizational skills with ability to trend and track audit findings effectively.
  • Excellent problem solving skills, the ability to work independently, and to perform under pressure in a teamwork manner with diplomacy and tact.
  • Proficient computer and technical skills, along with experience using MS Word, Excel and PowerPoint.
  • Ability to meet assigned deadlines.


  1. Education: Associates degree in Health Information (RHIT), or associates degree in applicable healthcare field.
  2. Experience 3-5 years progressive coding experience in acute care hospital setting, including auditing
  3. Certification/Licensure: AHIMA certification required, such as RHIA, RHIT or CCS,
  4. Software/Hardware: Meditech and 3M 360 experience required; Cerner experience helpful.
  5. Other: This is a remote position, and must live within a Steward hiring state.
  6. Travel: Expected travel is up to 10%. Education and/or company growth.

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