About the Role
This role focuses on improving the quality and completeness of clinical documentation through review, analysis, and collaboration with healthcare providers to ensure accurate representation of patient care.
Responsibilities
- Review medical records for documentation accuracy and completeness
- Identify gaps in clinical documentation that affect coding and billing
- Collaborate with physicians and clinical staff to clarify documentation
- Ensure compliance with regulatory and coding standards
- Support accurate severity of illness and risk of mortality scoring
- Respond to queries from coding and compliance teams
- Maintain up-to-date knowledge of coding guidelines and clinical trends
- Participate in ongoing education for healthcare providers
- Conduct audits of clinical documentation practices
- Provide feedback to improve documentation quality
- Work within electronic health record systems to access patient data
- Support quality reporting initiatives
- Assist in development of documentation improvement tools
- Track and report on documentation improvement metrics
- Engage in interdisciplinary team meetings
- Promote best practices in clinical documentation
- Evaluate documentation for alignment with diagnosis-related groups
- Facilitate timely resolution of documentation discrepancies
- Contribute to policy and procedure updates
- Ensure patient privacy and data security standards are followed
Nice to Have
- Certified Clinical Documentation Improvement Practitioner (CCDIP)
- Experience in a hospital-based CDI program
- Advanced knowledge of coding audit software
- Formal training in query writing and resolution
- Experience with physician education initiatives
- Background in critical care or complex medical specialties
- Familiarity with data analytics in healthcare
- Project management experience in clinical settings
Compensation
Competitive salary and benefits package
Work Arrangement
Hybrid work model with flexible scheduling options
Team
Collaborative environment with clinical and coding teams
About Us
We are a healthcare services organization dedicated to improving clinical outcomes through accurate documentation and data integrity. Our team works closely with providers to ensure patient records reflect the full scope of care delivered.
What We Offer
- Professional growth opportunities
- Flexible work environment
- Supportive team culture
- Access to ongoing training and certifications
- Health, dental, and retirement benefits
No visa sponsorship available
