Clinical Documentation Specialist
Lehigh Valley Health Network
full-time
Posted on:
Location Type: Remote
Location: Pennsylvania • United States
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About the role
- Responsible for improving the overall quality and completeness of clinical documentation in the medical record to reflect the severity of illness, clinical treatment, decisions and diagnoses of patients.
- Involves concurrent medical record review, DRG validation, querying providers, capture of clinical and quality indicators to ensure the thoroughness of documentation prior to coding and billing.
- Responsible for the day-to-day review and evaluation of clinical documentation by the Medical Staff and healthcare team in accordance with the network's designated clinical documentation policies and procedures.
- Calculates working DRG within CDI tracking systems/software.
- Performs follow-up on cases through patient discharge.
- Applies clinical knowledge and experience to the daily review and evaluation of the medical record including physician/clinical documentation, lab results, diagnostic information and treatment plans.
- Promotes integrity of clinical documentation and thoroughness of the medical record to ensure appropriate severity of illness, risk of mortality, length of stay and reimbursement are captured.
- Communicates with providers via verbal and/or electronic clinical documentation integrity queries to clarify missing, unclear or conflicting medical record documentation; identifies opportunities for service line and individual provider education and communicates to CDI leadership.
- Achieves key performance indicators in the areas of productivity/thoroughness and quality.
Requirements
- Bachelor’s Degree BSN, RHIA or Master’s Degree CRNP, PA-C or Associate’s Degree RN, RHIT or Specialized Diploma RN, CCS, CPC
- 5 years advanced coding or clinical experience in an acute care hospital setting or 1 year CDI or coding experience
- Experience with medical record reviews and/or DRG validation
- Proficient in MS Outlook, Word, Excel and PowerPoint
- Ability to acquire working knowledge of DRG assignment and methodology, coding practices and clinical documentation requirements
- Will demonstrate adaptability and self-motivation to stay abreast of CMS rules and regulations; incorporate those changes into daily practice; maintain knowledge of federal, state and private payor regulations and demonstrate knowledge and understanding of ICD-10 Coding Guidelines.
- Will demonstrate accountability, professional development, and adhere to departmental policies and guidelines.
- RHIT - Registered Health Information Technician - American Health Information Management Association Upon Hire or RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire or RHIA - Registered Health Information Administrator - American Health Information Management Association Upon Hire or CPC - Certified Professional Coder - American Academy of Professional Coders Upon Hire or CCS - Certified Coding Specialist - American Health Information Management Association Upon Hire
Benefits
- Competitive salary
- Health insurance
- Professional development opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical documentationDRG validationmedical record reviewcoding practicesICD-10 coding guidelinesclinical knowledgequality indicatorspatient discharge follow-upclinical documentation integrityperformance indicators
Soft Skills
adaptabilityself-motivationaccountabilityprofessional developmentcommunication
Certifications
RHIARHITCPCCCSRN