CLINICAL DOCUMENTATION SPECIALIST (Coder)
Full-time Benefits, This is a full-time, Perm Career
The Hospital is currently seeking a Clinical Documentation Specialist (CDI) who is responsible for providing clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Will play a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting qualify of care outcomes.
- Collaborates with physician, physician extender, nurse, case manager and Health Information management coder to identify areas for improved physician documentation.
- Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings on worksheets, denoting all key information utilized in the tracking process.
- Clarifies documentation in the records utilizing assertive communication skills to guide physician, case manager, or other healthcare professionals to make changes as appropriate to clarify documentation.
- Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality in compliance with all guidelines and requirements.
- Responds to physician queries.
- Enters working DRG's into the computerized clinical documentation system.
EDUCATION AND TRAINING
- Graduate of Nursing school, AHIMA accredited school, international medical school.
- Licensed Registered Nurse in the state of Missouri and/or RHIT, RHIA, or CCS Credential.
- Minimum three years clinical or inpatient coding experience in an accurate care setting required.
- Minimum five years experience strongly preferred.
SKILLS AND ABILITIES
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- Familiarity with coding concepts and coding software desired.
- Knowledge of care delivery documentation systems and related medical records documents.
- Knowledge of age-specific needs and the elements of disease processes and related procedures.
- Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
- Excellent written/verbal communication skill & excellent critical thinking skills
- Proven interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff, and health information systems coding staff.
- Ability to work independently in a time-sensitive environment.
- Computer literacy and familiarity with the operation of basic office equipment.
- Assertive personality traits to facilitate ongoing physician communication.
- Ability to stand and walk for periods of time is required in the performance of job responsibilities.
- Working knowledge of Medicare reimbursement system and coding structures/national coding guidelines.
- Management experience is not required.
National Recruiters LLC, is an Equal Opportunity Employer