Clinical Documentation Specialist
$78,000–$96,200 year
RemoteNew York, United States
Job Summary
Review medical records for completeness and accuracy regarding severity of illness, risk of mortality, complexity of care, and quality metrics. Formulate clinically credible documentation clarifications and request updates from physicians to ensure accurate coding for billing and reporting. Provide education to the patient care team regarding the clinical documentation improvement process and actively participate in team meetings. Manage multiple priorities while communicating with HIM staff to resolve discrepancies and ensure timely resolution of all cases. Accurately input data into department software and utilize ICD-10-CM guidelines to support appropriate diagnoses for skilled nursing facility authorizations.
Required Qualifications
- Registered nursing degree
- Current professional licensure in the state of New York based on degree
- Active unrestricted RN status
- At least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU
- CCDS or CDIP certification
- CCDS certification
- Understanding of Medicare Part A guidelines
- Understanding of the current FY SNF PPS Final Rule
- Understanding of the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings
- Understanding of the MDS Resident Assessment Instrument (RAI) Manual
- Ability to use the CMS PDPM Calculator Tool
Desired Qualifications
- CCDS certification
- Previous CDS experience
- Minimum 5 years short term acute medical/surgical hospital nursing experience
- BSN or RN with BS in applicable field
- Minimum of two years CDI experience
- Knowledge of payment methodologies and CMS/AHRQ Quality metrics
- Working knowledge of Epic EMR and Nuance CDE One
- 5+ years of adult acute care experience in Med/surg, critical care, emergency room, or PACU
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