Clinical Documentation Specialist
Foundation
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $45 - $63 per hour
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 & Tools
clinical documentationclinical codingdiagnosis codingprocedure codingDRG assignmentcritical thinkingdocumentation improvementabstractionconcurrent codingencoder technology
Soft Skills
interpersonal communicationcollaborationeducationanalytical skillsattention to detail
Certifications
CCSCDIPCCDS