Clinical Documentation Coordinator
On-siteLas Vegas, Nevada, United States
Job Summary
Improve the overall quality and completeness of clinical documentation by facilitating modifications through extensive interactions with physicians, nursing staff, Health Information Management coding staff, and other healthcare team members. Ensure appropriate reimbursement and clinical severity are captured for all patients with a DRG-based payer by interpreting patient charts to determine whether care given was appropriate and properly documented. Analyze statistical data and write reports, meeting minutes, and other technical documents while applying investigative and interviewing techniques to resolve departmental issues. Maintain complete confidentiality of medical records and physician information while communicating effectively with a wide variety of staff and supervisors. Work in a typical office setting, interpreting Medicare reimbursement systems, coding structures, and Joint Commission standards to ensure compliance with state statutes and hospital policies.
Required Qualifications
- Graduation from an accredited school of nursing
- Three (3) years of clinical nursing experience
- Three (3) years clinical documentation improvement experience
- Physician graduate International MD
- Three (3) years of acute care experience
- Three (3) years Clinical Documentation Improvement (CDI) experience
- Equivalent to a Bachelor's degree in Healthcare
- Three (3) years Health Information Management in an acute care hospital inpatient experience
- Three (3) years Clinical Documentation Improvement (CDI) experience
- Valid license by the State of Nevada to practice as a Registered Nurse
- Certified Clinical Documentation Specialist (CCDS)
- Certified Clinical Documentation Specialist-Outpatient (CCDS-O)
- Certified Document Improvement Practitioner (CDIP)
- International medical graduate degree
- Certified Document Improvement Practitioner (CDIP)
- Certified Clinical Documentation Specialist (CCDS)
- Certified Clinical Documentation Specialist-Outpatient (CCDS-O)
- Certification in Certified Coding Specialist (CCS)
- Certification in Registered Health Information Technician (RHIT)
- Certification in Registered Health Information Administrator (RHIA)
- Certification in Certified Professional Coder (CPC)
- Certification in Certified Professional Coder-Physician-based (CPC-P)
- Knowledge of Medicare reimbursement system and coding structures
- Knowledge of hospital policies and procedures
- Knowledge of Joint Commission Accredited Health care Organizations standards
- Knowledge of state statutes governing hospital services and health care
- Knowledge of Medicare/Medicaid guidelines and other relevant regulations and standards
- Knowledge of clinical medical and nursing procedures
- Knowledge of disease processes
- Knowledge of department and hospital safety practices and principles
- Knowledge of patient rights
- Knowledge of age specific patient care practices
- Knowledge of infection control policies and practices
- Knowledge of department and hospital emergency response policies and procedures
- Skill in Working effectively under pressure
- Skill in holding in complete confidence all information acquired from medical records and physicians
- Skill in interpreting patient charts to determine whether care given was appropriate and properly documented
- Skill in interpreting regulations and standards for others
- Skill in writing reports, meeting minutes and other technical documents
- Skill in analyzing statistical and other quantitative data
- Skill in critical thinking
- Skill in conflict management
- Skill in dealing with departmental issues involving self or other employees in professional, forthright and impartial manner
- Skill in applying investigative and interviewing techniques
- Skill in using a computer and a variety of software applications
- Skill in communicating with a wide variety and establishing interpersonal relationships to interact effectively with co-workers, supervisor, staff in other work units and exchange or convey information
- Mobility to work in a typical office setting and use standard equipment
- Stamina to remain seated for extended periods of time
- Vision to read printed materials and a VDT screen
- Hearing and speech to communicate effectively in person and over the telephone
- Strength and agility to exert up to 10 pounds of force occasionally and/or an eligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects
- May work shifts and weekends
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