Clinical Documentation Improvement Specialist
$45,760–$56,160 year
HybridOneida, New York, United States
Job Summary
Clinical Documentation Improvement Specialist to enhance accuracy and completeness of clinical documentation within the Meditech EHR. Responsibilities include reviewing patient records, collaborating with physicians and nurses to ensure precise coding, educating staff on best practices for documentation and coding guidelines, analyzing coding/documentation trends for process improvements, developing and implementing related policies and procedures, and staying current with coding guideline changes and Meditech updates. Strong communication and collaboration with multidisciplinary teams required.
Required Qualifications
- Bachelor's degree in nursing, health information management, or relevant field
- Proficiency with Meditech EHR system
- Strong knowledge of coding guidelines, healthcare regulations, and clinical documentation requirements
Desired Qualifications
- CCDS or CCS certification preferred
- Experience with Meditech EHR
- Healthcare coding knowledge
- Clinical documentation improvement experience
- Education/training development experience
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