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Clinical Documentation Specialist
INTEGRIS HealthClinical Documentation Specialist at INTEGRIS Health responsible for evaluating completeness and quality of clinical documentation. Partnering with healthcare professionals to ensure accurate patient records in Oklahoma City.
About the role
Key responsibilities & impact- Evaluating overall completeness and quality of clinical documentation
- Works in partnership with physicians, coders, and other healthcare professionals
- Performs concurrent review process for all selected admissions
- Demonstrates in-depth clinical knowledge of complex disease processes and procedures in an inpatient setting
- Utilize current CMS, AHA, and AHIMA coding guidelines to accurately determine diagnoses and procedures
- Develop documentation query protocol and educate essential staff
- Initiates assertive communication with physicians when documentation requires clarification
- Tracks responses and trends compliance with documentation queries
- Identifies trends in documentation and/or potential problems and develops action plans
- Works effectively with coding staff to clarify documentation issues
- Provides information and education to physicians not responding to documentation requests
- Conducts independent research to promote knowledge of clinical topics and trends
Requirements
What you’ll need- RN with 3 years relevant experience, OR RHIT with 3 years relevant experience, OR RHIA with 3 years relevant experience, OR CCS with 3 years relevant experience
- 5 years of acute care hospital coding with a strong DRG background; or strong medical background with 5 years acute clinical experience preferred
Benefits
Comp & perks- front-loaded PTO
- medical benefits through the extensive INTEGRIS Health network
- financial assistance for continued education
- 24/7 mental health support
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
Clinical Documentation EvaluationConcurrent Review ProcessDocumentation Query Protocol DevelopmentDisease Process KnowledgeDRG Background
Soft Skills
Assertive CommunicationCollaborationEducation and Training
Certifications
RNRHITRHIACCS