Steward Health Care System
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HIM Inpatient Coding Auditor
at Steward Health Care System
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.
- Education: Associates degree in Health Information (RHIT), or associates degree in applicable healthcare field.
- Experience 3-5 years progressive coding experience in acute care hospital setting, including auditing
- Certification/Licensure: AHIMA certification required, such as RHIA, RHIT or CCS
- Software/Hardware: Meditech and 3M 360 experience required
- Other: Required to work out of Steward Health Care office located in Richardson, Texas.
- Travel: Expected travel is up to 10%. Education and/or company growth.
- 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.
- Performs other duties as assigned including training/mentoring of new staff and performing research related to special projects