Job Description

Location: Morton Hospital
Posted Date: 1/19/2024
Job Type: Per Diem
Department: 2100.70900 SMH Medical Records

About Steward Health Care
Over a decade ago, Steward Health Care System emerged as a different kind of health care company designed to usher in a new era of wellness. One that provides our patients better, more proactive care at a sustainable cost, our providers unrivaled coordination of care, and our communities greater prosperity and stability.

As the country's largest physician-led, minority-owned, integrated health care system, our doctors can be certain that we share their interests and those of their patients. Together we are on a mission to revolutionize the way health care is delivered - creating healthier lives, thriving communities and a better world.

Based in Dallas, Steward currently operates more than 30 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas.

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***Medical Records Coder Per Diem


Reviews hospital medical records and/or reports to determine all diagnoses and procedures; assigns the correct ICD9-CM and/or CPT code; adheres to accepted coding conventions; accurately inputs information into Meditech for purposes of reimbursement and clinical and financial decision making.


  • Reads and interprets health record documentation to identify all diagnoses and procedures that affect the inpatient/outpatient stay/visit.
  • Assesses the adequacy of health record documentation to ensure that it supports all diagnoses and procedures to which codes are assigned.
  • Applies knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to assign accurate codes to diagnoses and procedures.
  • Applies knowledge of current approved coding guidelines (as published in Coding Clinic for ICD9-CM) to assign and sequence the correct diagnosis and procedure codes for hospital inpatient services with a 95% accuracy rate.
  • Applies knowledge of current coding guidelines and regulatory agency guidelines to assign the correct diagnosis and procedure codes for hospital outpatient services with a 95% accuracy rate
  • Applies knowledge of CPT format, guidelines and notes to locate the correct codes for all services and procedures performed during the encounter/visit and sequence them correctly.
  • Applies Uniform Hospital Discharge Data Set (UHDDS) definitions to select the principal diagnosis, principal procedure, complications and comorbid conditions, and other diagnoses and significant procedures which require coding.
  • Applies knowledge of the Prospective Payment System to confirm DRG assignment which ensures optimal reimbursement.
  • Refuses to fraudulently maximize reimbursement by assigning codes that do not conform to approved coding principles/guidelines.
  • Applies knowledge of the Outpatient Prospective Payment System to confirm APC/APG assignment which ensures optimal reimbursement.
  • Applies knowledge of ICD9-CM instructional notations and conventions to locate and assign the correct diagnostic and procedural codes and sequence them correctly.
  • Attaches modifiers to procedure or service codes when applicable.
  • Accurately codes for the professional vs. technical component when needed.
  • Clarifies conflicting, ambiguous, or nonspecific information appearing in the record by consulting the appropriate physician.
  • Participates in quality assessment to ensure continuous improvement in ICD9-CM and CPT coding and collection of quality health data.
  • Demonstrates the ability to recognize potential coding quality issues from an array of data.
  • Accurately enters data into Meditech, verifying any existing information.
  • Participates in educational sessions for physicians and hospital staff on coding, reimbursement, and documentation rules.
  • Orients, trains, and evaluates new coding staff
  • Assists in the updating to the charge description master when needed
  • Prioritizes coding functions to meet hospital time frames
  • Conducts meetings for coding staff on a monthly basis


  • Is cooperative in interactions, treating customers with courtesy, respect and compassion.
  • Is patient when responding to questions and answers questions appropriately
  • Responds to requests in a timely manner
  • Handles interruptions in a skillful way
  • Manages a professional appearance and demeanor
  • Strives to prevent/resolve customer concerns to the customer’s satisfaction.


  • Is responsible for ongoing development of his/her work skills through the use of available resources (i.e. in-services, formal educational programs, other work groups and on-the-job training).
  • Attends and participates in staff meetings and in-services and/or reviews documentation as required.
  • Assists in the orientation of others and actively participates in mentoring.
  • Performs analytical and decision making functions with minimal supervision.
  • Recognizes and seeks assistance/consultation when appropriate.
  • Demonstrates an understanding of relative Hospital and all-departmental policies and procedures including safety issues.
  • Possesses awareness of programs/services provided by Hospital and where they are located.


Required Qualifications: Two to four years coding experience in a health care setting; working knowledge of ICD9-CM and CPT-4 coding systems and prospective payment systems.

Preferred Qualifications: Certified Coding Specialist or Accredited Health Information Technician credentials preferred. Inpatient coding experience preferred

Steward Health Care is proud to be a minority, physician owned organization. Diversity, equity, inclusion and belonging are at the foundation of the care we provide, the community services we support and all our employment practices. We do 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

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