Responsibilities
- Ensure overall quality and completeness of medical record documentation.
- Facilitate modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other caregivers, and Health Information coding staff to support appropriate reimbursement and capture of clinical severity for all inpatients.
- Support timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
- Educate all members of the patient care team on an ongoing basis.
- Act as a professional team player with strong communication skills across all levels.
- Maintain regular significant contacts with other personnel throughout and outside the hospital.
- Communicate in person, by telephone, or through correspondence.
- Be flexible with a working knowledge of all areas of adult medicine.
- Occasionally lift or carry up to fifteen pounds, and perform reaching, stretching, stooping, bending, kneeling, crouching, standing, walking, and pushing or pulling to move and file medical records alone or in carts.
- Sit for long periods, and have manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader or printer, and other office equipment.
- Adequately perform essential job functions with the type of judgments and potential consequences outlined above.
Requirements
- Minimum 5 years experience as a Clinical Documentation Specialist in an acute setting, preferably a Level 1 Trauma Center.
- Subject matter expert in CDI for all payors and all DRG groups (MS-DRG, APR-DRG, AP-DRG Elixhauser, risk variables), with knowledge and experience in PSI, HAC, HCC (risk adjustment coding), and Vizient Calculator.
- Registered Nurse in any state.
- CCDS or CDIP certification.
- Registered Nurse in any state.
- Coding certification: CCS or CRC; CIC is an acceptable equivalent.
- Excellent critical thinking skills, with ability to assess, evaluate, and teach.
- Must be self-governed, disciplined, and organized.
- Requires excellent work ethic, analytical thinking, problem solving, excellent computer skills, and excellent verbal and written communication with knowledge of email etiquette.
- Proficient in Word, Excel, PowerPoint, and typing at 60 WPM.
Nice to Have
- BSN or higher preferred.
- BSN or higher preferred.
Work Arrangement
Remote
Other
- Occasional lifting or carrying up to fifteen pounds, as well as reaching, stretching, stooping, bending, kneeling, crouching, standing, walking, and pushing or pulling to move and file medical records alone or in carts.
- Ability to sit for long periods of time, manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader or printer, and other office equipment.
