Steward Health Care
Remote * (Westwood, MA, USA)
Position Summary 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. Key Responsibilities 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...
