Position Title: Clinical Documentation Specialist
Position Summary: To assist the hospital in achieving compliant, clear, complete, concise, concurrent documentation to support quality care and efficient and thorough post discharge coding for accurate classification and receipt of legitimate reimbursement optimization as well as to mitigate risk within the legal health record.
Essential Duties and Responsibilities:
• Provides concurrent review of clinical documentation in medical records
• Queries medical staff and other caregivers as necessary to obtain accurate and complete documentation that supports severity of patient illness and risk of mortality
• Performs a thorough chart review to identify co morbidities/complication, and documents these appropriately within the concurrent DRG worksheet
• Demonstrates and understands the importance of and make an effort to capture all appropriate secondary diagnoses for quality rating/proofing purposes
• Provides feedback to medicals staff and conduct education
• Promotes a clean and safe environment of care, utilizing the SAFE error prevention habits
• Provides the highest standard of privacy and confidentiality in matters involving patients, coworkers, and the hospital by abiding by the Standards of Conduct
Required Qualifications:
Education and Training:
• A minimum of a bachelor’s degree plus an RHIA®, RHIT®, CCS®, CCS-P®, RN, LVN, MD or DO and two (2) years of experience in clinical documentation improvement or inpatient coding OR
• A minimum of a bachelor’s degree (or equivalent education) in an allied health field and three (3) years of experience in clinical documentation improvement or inpatient coding. The education component must include completed coursework in medical terminology and anatomy and physiology.
• Excellent verbal, written, presentation, computer and interpersonal communication skills.
• CCDS and/or CDIP Certification is ideal.
• Highly Desired: ICD-10-CM/PCS Coding training and certification (may be provided on job)
Work Shift Details:
Days, Remote
Department:
CLINICAL DOCUMENTATION