CLINICAL DOCUMENT SPECIALIST
On-siteMerrillville, Indiana, United States
Merrillville, Indiana, United StatesOn-siteFull TimeLarge
Full TimeLarge
Job Summary
Facilitate concurrent medical record documentation to ensure accurate inpatient coding, DRG assignment, and billing integrity. Review provider documentation, electronically query physicians for missing or unclear information, and resolve queries prior to patient discharge. Complete admission reviews within 24-48 hours of admission and conduct follow-up reviews up to four days later. Collect and analyze data to generate reports, make recommendations for process improvements, and contribute to staff education on documentation guidelines.
Required Qualifications
- Registered Health Information Technologist/Registered Health Information Administrator
- An Associate's Degree from a recognized college or university in Nursing and a current Registered Nurse licensure in the State of Indiana
- A Bachelor's Degree from a recognized college or university in health records management or a closely related field and RHIA
- Minimum 2 years inpatient hospital coding experience
- 2 years Healthcare/Medical - Health Information Systems/Technology/MIS Required
- Minimum 3 years' experience in Clinical documentation Improvement
- Minimum 3 years' experience in hospital inpatient quality chart review or Case Management
- RHIA - Registered Health Info Administrator
- RHIT - Registered Health Info Technician
- Licensed Registered Nurse
- Excellent communication skills
- Ability to work independently and in a team environment
- Self-starter, professional courtesy, positive attitude
- Demonstrates knowledge of procedures for protecting and maintaining security, confidentiality, and integrity of employee, patient and family, organizational, or other medical information
- Understands and supports the commitment of Methodist Hospitals in adhering to federal, state, and local laws, rules, and regulations governing ethical business practices for healthcare providers
Desired Qualifications
- Associates Nursing Required
- Bachelors Health Information Required
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