Clinical Documentation Specialist
On-siteMidland, Texas, United States
Job Summary
Conduct concurrent reviews of clinical documentation in medical records to ensure accurate levels of care and diagnoses. Query physicians and nursing staff via written or verbal communication to obtain complete documentation supporting patient severity and mortality risk. Analyze charts for diagnosis clarification, validity, and opportunities to capture secondary diagnoses for DRG assignment and profiling. Navigate electronic health records to verify signs, symptoms, and comorbidities while adhering to AHIMA and ACDIS guidelines. Develop and present ongoing documentation education for clinical staff. Requires current RN license with five years acute care experience or comparable degree with coding certification. Onsite Monday through Friday from 8:00 AM to 5:00 PM.
Required Qualifications
- High school graduate or equivalent
- Registered Nurse – current license (ADN or BSN)
- 5 years acute care experience
- Comparable degree in a healthcare-related discipline
- 3-5 years recent coding experience
- Certification of one of the following: Certified Coding Specialist (CCS), Certified Documentation Integrity Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS)
- Strong broad-based clinical knowledge and understanding of pathology/physiology
- Knowledge of age-specific needs and the elements of disease processes and related procedures
- Able to convert weights and measures for clinical application
- Ability to analyze collected data to define and address issues
- Excellent written and verbal communication skills
- Critical thinking skills
- Computer literacy and familiarity with the operation of basic office equipment
- Must be able to stand, walk, sit, stoop, reach, lift, see, speak and hear
- Lifting limited to 35 lbs. for clinical staff
- Lifting limited to 50 lbs. for non-clinical staff
- Must use an assisted-lift device or get another individual(s) to assist with the lift that is over these maximum limits
- Onsite work location
Desired Qualifications
- Working knowledge of Medicare reimbursement system and coding structures preferred, but not required
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