Job Description

Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.

• Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients
• Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis
• Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities
• Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses - obtaining missing information via a query when necessary

Clinical Documentation Specialist Qualifications

• Must have at least one of the following:
  • License to practice as a Registered Nurse preferred (any state)
  • Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)
• Must have all of the following:
  • 1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience
  • CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required

Additional notes:

 

Candidate must have at least 1 year of experience with concurrent inpatient facility coding/clinical documentation improvement experience. We are looking for someone who has had experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records

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