The Clinical Documentation Specialist will conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation of acute care services. This individual will work closely with physicians and medical staff to facilitate appropriate physician documentation of patient care.
Experience Required:
- Has an active RN license with 3+ years of floor experience
- 3+ years of CDI experience
- Knowledge of what conditions impact reimbursements
- CCDS or CPC Certification, optional
Job Responsibilities:
- Clinically evaluate how the health record translates into coded data, including review of Provider and other clinician documentation, lab results, diagnostic information, and treatment plan.
- Provide concurrent and/or retrospective review
- Improve documentation of all conditions, treatments, and care plans to ensure the highest quality of care is provided to the patient.
- Communicate with Providers via phone call and/or email regarding missing, unclear, or conflicting health record documentation, and clarify the information as warranted.
- Gather and analyze information pertinent to documentation findings and outcomes, and use this information to develop action plans for process improvement.
- Demonstrate understanding of complications, comorbidities, and the impact of procedures on the billed record, as well as the ability to impact this knowledge to providers and other members of the healthcare team.
Soft Skills:
- Possess strong verbal and written communication skills
- Demonstrates a high level of accuracy, in a fast-paced environment
- Ability to multi-task
Job Types: Full-time, Contract
Pay: $52.00 - $55.00 per hour
Expected hours: 40 per week
Benefits:
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
Experience:
- Clinical Documentation Integrity (CDI): 3 years (Required)
License/Certification:
- RN (Required)
- CCSD (Preferred)
- Certified Professional Coder (Preferred)
- CRC (Preferred)
Work Location: Remote
