Job Title: Clinical Documentation Specialist / CDI
Position Type: Remote
Facility Address: 800 East Dawson Street, , Tyler, TX, 75701
Shift: 0800-1700 (Mon-Fri)
Contract Weeks: 12
Pay Rate: $50/hr to $57/ hr on W2
GUARANTEE: 40-hrs
SYSTEM: Meditech
PROOF of EDUCATION: Diploma, transcript or GED copy of certification, or Current TX RN (or compact) license is required
REQUIRED EDUCATION/CERTIFICATION: MD or RN with clinical documentation and coding experience in addition
Foreign or Domestic Medical School Graduate (license not required) OR
Graduate from Physician's Assistant or RN Program
Graduate from Registered Nurse Practitioner program preferred.
Note: A minimum of 3 years of experience (HIM) in area of population to be served is required.
Three (3) years previous acute hospital inpatient coding experience highly preferred
M.D. or D.O.; ECFMG certification (preferred for Foreign Medical Graduates)
RN or Current PA or RNP license required, as approved
Certified Clinical Documentation Specialist (CCDS) highly preferred or CCS (Preferred)
Job Description:
Clinical Documentation Specialist Responsibilities:
- Applying knowledge of medical terminology and procedures to evaluate clinical documents.
- Collecting medical information from healthcare providers and updating medical records.
- Verifying the accuracy of patient medical information and obtaining missing information.
- Monitoring diagnoses, treatments, and follow-up entries in medical records.
- Interpreting and preparing clinical reports for healthcare professionals and public health officials.
- Meeting with healthcare stakeholders to explain findings and facilitate actions.
- Ensuring that the content and storage of medical documents comply with federal laws.
- Training medical and administrative staff in standard medical recordkeeping procedures.
- Keeping abreast of advancements in the field of clinical documentation and changes in regulations.
Clinical Documentation Specialist Requirements:
- Associate's or bachelor's degree in health information technology.
- Registered Health Information Technician (RHIT) preferred.
- Registered Nurse (RN) will be advantageous.
- Proficiency in Electronic Medical Record (EMR) software, such as eClinicalWorks and Praxis.
- A minimum of 3 years experience in a similar role.
- Advanced knowledge of best practices in medical recordkeeping.
- In-depth knowledge of medical terminology, coding, and procedures.
- Extensive experience in collecting and interpreting medical information, as well as training staff.
- Ability to keep informed of advancements and regulations in clinical documentation.
- Excellent organizational and communication skills.
Job Type: Contract
Pay: $55.00 - $57.00 per year
Benefits:
- 401(k) matching
- Health insurance
- Life insurance
Schedule:
- 8 hour shift
- Monday to Friday
Application Question(s):
- Do you have Diploma, transcript or GED copy of certification, or Current TX RN (or compact) ?
Education:
Experience:
- HIM OR Acute hospital inpatient coding: 3 years (Required)
License/Certification:
- RHIA/RHIT Certificate (Required)
- Certified Coding Specialist (Preferred)
- CDIP (Preferred)
- CCDS (Preferred)
Work Location: Remote
