Clinical Documentation Specialist, Case Management, Full Time, Flexible Shift

Full Time
Hialeah, FL 33016
Posted
Job description

About Steward Health Care
Nearly 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, tax paying, 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.
Steward is among the nation’s largest and most successful accountable care organizations (ACO), with more than 5,500 providers and 43,000 health care professionals who care for 12.3 million patients a year through a closely integrated network of hospitals, multispecialty medical groups, urgent care centers, skilled nursing facilities and behavioral health centers.
Based in Dallas, Steward currently operates 39 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, Texas, and Utah.
For more information, visit www.steward.org.

Position Summary:

Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Include facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Will play a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting quality of care outcomes.

Position Qualification: (Training, Education, Experience, Skills and Abilities) Preferred:

  • 5 years Clinical or Inpatient coding experience preferred.

EDUCATION: RN or LPN license or RHIA, RHIT, or CCS credential; a graduate of a foreign medical school would also be considered.

TRAINING: Orientation and training under supervision of HIM Director and Coding Manager until competency is observed.

ABILITIES AND SKILLS:

  • Familiarity with coding concepts and coding software desired. Knowledge of care delivery documentation systems and related medical record documents.
  • Knowledge of age-specific needs and the elements of disease processes and related procedures.
  • Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
  • Excellent written and verbal communication skills.
  • Excellent critical thinking skills.
  • Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff, and health information management coding staff.
  • Ability to work independently in a time-sensitive environment.
  • Computer literacy and familiarity with the operation of basic office equipment.
  • Assertive personality traits to facilitate ongoing physician communication.
  • Ability to stand and walk for periods of time is required in the performance of job responsibilities.
  • Working knowledge of Medicare reimbursement system and coding structures/national coding guidelines.

EXPERIENCE: 3 years clinical or inpatient coding experience in an acute care setting required; 5 years’ experience strongly preferred.

Required Licenses/Certifications: RN, LPN, RHIA, RHIT, CCS, or Foreign Medical Graduate.

Language Skills:

  • Ability to effectively communicate (verbally and in writing) in English.
  • Ability to write legibly (Clinical Areas).
  • Additional languages desirable.


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.


Location: South · 8329.46014 Quality & Case Management CC
Schedule: Full Time, Flexible hours, Full Time

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