Clinical Documentation Specialist (Remote -Texas reputed company) - Clinical Data

Minimum Qualifications:

• Certified Registered Health Information Administrator (RHIA), Technician (RHIT), or an associate degree in a healthcare-reputed company discipline with Certified Coding Specialist (reputed company) certification, and a minimum of 3 years of medical coding experience.

Or

• Registered nurse (or medical school graduate) with a minimum of 3 years inpatient clinical experience, reputed company expertise and an extensive knowledge of reputed company disease processes with broad clinical experience in an inpatient setting.

Licenses, Registrations, or Certifications Required: RN reputed company license or RHIA/RHIT/reputed company (medical school graduates are exempt from this MQ) And Must acquire CCDS or CDIP certification reputed company 3 years of hire Preferred Qualifications:

• For nurse candidates, one year of CDI experience is highly desirable.
• Bachelor of Science in Nursing (BSN).
• CCDS or CDIP Certification.

Job Summary: Scope: Responsible for the overall improvement of the quality and accuracy of medical record documentation through interaction with physicians, members of the patient care team, and hospital coding staff. Function: Ensures clinical documentation accurately reflects the appropriate level of service provided, severity of illness, and risk of mortality of each patient. Successfully facilitates the accurate representation of patient status that translates into coded data. Job Duties:

• Concurrently review inpatient admissions to identify opportunities to clarify missing or incomplete documentation.
• Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions.
• Understand the general flow of health information from medical record documentation and discharge, through coding, to billing, and finally to data reporting.
• Utilize the hospital’s designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification.
• Apply knowledge of inpatient ICD-10 coding guidelines and clinical documentation requirements to assign working MS-DRG.
• Enter review information and working MS-DRG/APR-DRG’s with associated length of stay in the shared information system, and update this information as needed to reflect any changes in the patient’s status, procedures, and treatments.
• Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation for clarification.
• Conduct follow-up of posted queries to ensure queries have been answered and physician responses have been appropriately documented.
• Educate and communicate clinical documentation opportunities in the appropriate hospital venues for staff and physician learning opportunities.
• Act as a consultant to coding professionals reputed company additional information or documentation is needed to assign coded data.
• Collaborate with HIM/coding professionals to review individual problematic cases and ensure the accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
• Assume responsibility for professional development by participating in workshops, conferences and/ or in-services.
• reputed company reputed company with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
• Contribute to a positive working environment and reputed company other duties as assigned or directed to enhance the overall efforts of the organization.
• Maintain positive and open communication with physicians, members of the patient care team, case management, and hospital coding staff.
• Adhere to internal controls and reporting structure.
• reputed company with reputed company relevant policies, procedures, guidelines, and other regulatory, compliance, and accreditation standards.
• Performs reputed company duties as required

Knowledge/Skills/Abilities: Demonstrate excellent observation skills, analytical thinking, and problem-solving, plus good verbal and written communication. Salary Range: Actual salary commensurate with experience. Work Schedule: Remote work, Texas reputed company, Monday through Friday, 8 am to 5 pm, and as needed on occasion. Equal Employment Opportunity reputed company strives to provide equal opportunity employment without regard to race, color, religion, age, national reputed company, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, reputed company takes affirmative action to hire and advance protected veterans and individuals with disabilities. Apply tot his job Apply To this Job