Clinical Documentation Specialist
Foundation
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteSalary
💰 $45 - $63 per hour
Job Level
JuniorMid-Level
About the role
- Responsible for facilitating the improvement to the overall quality and completeness of clinical documentation.
- Seeks to obtain appropriate and accurate clinical documentation reflective of the severity of illness and risk of mortality.
- Ability to analyze clinical information and using critical thinking skills identify documentation opportunities.
- Assigns a working DRG for each inpatient admission for assigned population of patients.
- Interacts thoughtfully with physicians and other member of the patient care team to gather accurate and timely clinical information for abstraction into designated database.
- Queries physicians using the approved query process in order to obtain clinical information as identified.
- Provides ongoing education regarding documentation guidelines to members of the patient care team.
- Assigns diagnoses and procedure codes to inpatient records based upon clinical record documentation and obtains a working DRG.
- Partners with Nurse Case Managers and physicians to identify opportunities for documentation improvement to support patient severity of illness and risk of mortality.
- Works collaboratively with Nurse Case Managers during the patient’s episode of inpatient care to assist physicians and other practitioners to document diagnoses and procedures clearly.
Requirements
- Associates and / or Bachelors degree in Health Information Management and /or a coding certification (CCS).
- Two (2) years inpatient Clinical Coding experience required or completed competency assessment for inpatient coding at City of Hope.
- Familiarity with Concurrent Coding models highly desirable.
- Proficiency with Encoder / Grouper technology and basic keyboarding skills.
- Successful completion of required education courses.
- CCS, CDIP or CCDS required
Benefits
- Comprehensive Benefits
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical documentationclinical codingdiagnosis codingprocedure codingDRG assignmentcritical thinkingdocumentation improvementabstractionconcurrent codingencoder technology
Soft skills
interpersonal communicationcollaborationeducationanalytical skillsattention to detail
Certifications
CCSCDIPCCDS