Job Description

Location: Carney Hospital
Posted Date: 3/1/2023

At Steward Health Care System, we are committed to improving the health of our communities by delivering exceptional, personalized health care with dignity, compassion and respect. Our continued focus on the patient experience informs our caregivers in how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values.

We dedicate ourselves in the communities we serve to delivering affordable health care to all and being responsible partners. No matter what your role, as a member of the Steward family, you are a specialist in the making every patient and family feel right at home, every co-worker a key to our success, and every referring practice, a team of prized colleagues.

In support of this, we commit ourselves to the following values:






If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.


(Briefly describe the overall purpose of this position - Why does it exist and how does it contribute to the overall organization?)

To ensure the quality and efficiency of inpatient/outpatient coding that includes qualitative coding, abstracting, data analysis, quality control and case mix monitoring. Performs coding audits for accurate code assignments. Reviews other records for coding accuracy as necessary. Leads coding integrity-related projects including coding validation, data analysis, productivity monitoring, performance reporting and coding education.


(Use bullets for specific responsibilities)

  1. Under the direction of the Director of HIM, and within established hospital and departmental policies and procedures, performs ongoing audits of inpatient and outpatient records to validate the assignment of ICD-9-CM, CPT, HCPCS Level II, POA indicators and modifier codes to ensure accurate MS-DRG, DRG, and APC assignments.

  1. Continuously evaluates the quality of clinical documentation to identify code omissions and other problem areas that impact code assignments. Works closely with Quality and CDI programs. Prepare summary reports of identified areas for improvement to management.

  1. Monitors case mix and identifies practice patterns, trends, root causes for variations in coding. Makes recommendations to HIM management for process/performance improvement.

  1. Demonstrates knowledge and proficiency with HIM software applications, groupers and operational systems relative to coding and reimbursement. Facilitates system updates in conjunction with Steward IT including testing and post-implementation review. Reports to management any identified system problems.

  1. Provides education and training to coding staff. Communicates timely feedback of validation findings. Reviews coding guidelines and practices, proper documentation techniques, medical terminology, and disease processes as it relates to the coding performance to ensure uniformity, consistency and accuracy.

  1. Maintains current knowledge of developments and trends in prospective payment, coding guidelines and related health care delivery issues.

  1. Assists in the dissemination of coding information to coding personnel including proposed changes in regulations and the anticipated impact on the Hospital.

  1. Participates in updating/revising policies and procedures as appropriate and ensures they reflect recognized coding guidelines.

  1. Abides by the Standards of Ethical Coding as set forth by the American Health Information Association. Monitors coding staff for adherence to ethical conduct and reports concerns to HIM management.

  1. Works closely with Patient Financial Services, Case Management and Patient Access staff to ensure accurate and timely coding. Assists in the monitoring of account receivables to meet the department’s established threshold

  1. Assists in the preparation of educational programs for the medical staff and departmental personnel on coding related topics.

  1. Prepares monthly quality and productivity coding reports.

  1. Reviews and responds to all coding related denials and prepares written appeals in accordance with the findings.

  1. Responds to all internal/external questions regarding the accuracy of code assignments.

  1. Establishes coding network among staff for continuing education.

  1. Assists in the selection, training and orientation of coding staff.

  1. Maintains professional development through attendance at in-service education programs and outside conferences.

  1. Oversees and validates the accuracy of outsourced coders’ performance.

  1. Performs coding and other related duties as required.

  1. Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
  • Commits to recognize and respect cultural diversity for all customers (internal and external).
  • Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.

  1. Performs other duties as assigned.


(Examples: Ability to work independently and take initiative; Good judgment and problem solving skills; Communication skills; Interpersonal and organizational skills; Level of confidentiality)

Knowledge of all aspects of hospital coding. Strong understanding of coding guidelines, prospective payment systems, CMS reimbursement regulations, and OIG Work plans. Excellent interpersonal skills. Ability to to teach and motivated team members. Highly organized with strong project/task management skills.


  1. Education: Associate Degree in HIM, Bachelor’s degree preferred.
  2. Experience 5 years of Acute Care hospital Coding. Validation experience preferred.
  3. Certification/Licensure: CCS required and RHIT or RHIA preferred
  4. Software/Hardware: Microsoft Applications, Encoder/Coding & Reimbursement Systems, Meditech a plus
  5. Other:

Additional Information

Important COVID message

Please note, our Carney Hospital is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment - with confidence and without fear. Our Safe and Ready program consists of a rigorous [five-point] standard ensuring patient safety, confidence and convenience: Expanded hours will allow previously canceled procedures to be scheduled as quickly as possible. Any COVID-19 related care takes place in designated areas away from other patients and their families. Emergency Departments are reorganized to be a safe place to treat all emergency patients. A stringent cleaning policy has been implemented throughout the hospital. A strictly controlled visitor and masking policy is required for patient safety. You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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