Documentation Specialist

Clinical Documentation Specialist

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We're committed to bringing passion and customer focus to the business.

Day Shift - 7.5 Hours (United States of America) The Clinical Documentation Specialist facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, coding professionals, and nursing staff. Active participation in team meetings and training of staff in the Nuance CDI process is a key role.

Major Role:

• Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
• Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission, quality measures, and patient safety indicators.
• Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff.
• Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient's clinical status and care.
• Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.

Skills Required:

• Organizational, analytical, and writing skills
• Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills
• Excellent time management
• Effective and appropriate communication with physicians & coding professionals
• Knowledge of regulatory guidelines
• Knowledge of Medicare Part A and MS-DRG and/or APR-DRG payment methodologies
• Ability to pass a written clinical competency assessment
• Basic computer skills

Requirements:

• A Bachelor of Science degree in Nursing or International Medical Graduate
• Must possess minimum 5 years of acute care hospital experience
• AHIMA CCA or CCS certification preferred
• ACDIS CCDS or AHIMA CDIP certification preferred
• Minimum 2 years of Inpatient Coding experience with ICD-10 CM/PCS.
• CDI experience preferred

This is a remote position, flexible hours 8a-4p, 9a-5p

Salary Range: $80,000 - $90,000

Employment Non-Discrimination: Richmond University Medical Center is committed to equality of opportunity in all aspects of employment and provides full and equal employment opportunities to all employees and potential employees without regard to race, color, national origin, religion, gender identity, sex, sexual orientation, pregnancy, childbirth and related medical conditions and needs including lactation accommodations, physical or mental disability, age, immigration or citizenship status, veteran or active military status, genetic information, or any other legally protected status.