Clinical Documentation Specialist

Overview

MUST HAVES/JOB DETAILS: • Current license to practice as a Registered Nurse (RN) in the State • 2+ years of recent and relevant clinical experience required. • 2+ years experience in CDI (clinical documentation improvement), ICD-9-CM and DRGs. • 2+ years experience in providing physician and coder education in an acute care setting. • Previous experience working in a CDI (clinical documentation improvement) department or as a consultant. • Minimum of one-year auditing experience. WHAT YOU NEED TO KNOW: • This individual will possess a broad knowledge of documentation requirements for accurate ICD-9-CM, ICD-10-CM/PCS and MS-DRG assignment. • This knowledge will play a key role in determining the reimbursement and quality potential of facilities. • Adherence to official coding compliance regulations, corporate policies developed to ensure accurate billing, and industry best-practice is essential. • The documentation specialist is on–site and available five days a week and may be required to work and an occasional weekend or holiday to ensure coverage. RESPONSIBILITIES: • Performance of inpatient medical record audits • Issuance of compliant, Client-approved, best-practice physician documentation clarification requests • Tracking and reporting of CDIS activities • Development and delivery of Physician, Coder and Clinical Documentation Improvement Specialist (CDIS) education through a variety of modalities • Providing coders, senior leadership and facility personnel orientation to documentation improvement activities

Benefits