Clinical Documentation Specialist (Full-Time)

Qualifications

• Two years of experience in an Inpatient Clinical Documentation Integrity Specialist (ICDIS) role, concurrent review of medical records in the field of ICDI and experience in a production role within the last 12 months

• High School diploma or GED required

• Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Registered Nurse (RN), Registered Respiratory Therapist, Certified Coding Specialist (CCS), or Certified Coding Specialist-Physician-based (CCS-P), or International or Domestic Medical Degree

• Demonstrated skills in analytical thinking, problem solving

• Effective verbal and written communication including ability to present ideas and concepts effectively to physicians, management and other members of our healthcare team

• Self-motivated and able to work independently without close supervision

• Demonstrated ability to work well with others in a creative and challenging work environment

• Must be able to work flexible hours which may include evenings and weekends as required to meet business needs

• Certified Documentation Improvement Practitioner (CDIP) certification or Certified Clinical Documentation Specialist (CCDS) certification

Responsibilities

• The Inpatient Clinical Documentation Integrity (ICDI) Specialist is accountable for reviewing patient medical records in the inpatient and/or outpatient setting to capture accurate representation of the severity of illness and facilitate proper coding

• Validates coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care

• Documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care

• Utilizes advanced knowledge of disease processes (pathophysiology), medications, and have critical thinking skills to analyze current documentation to identify gaps

• Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality and effective coding

• Understands and applies regulatory compliance related to documentation, coding and billing for all health insurance plans

• Facilitates appropriate modifications to documentation through extensive interactions and collaboration with physicians, coding, case management, nursing and other care givers

• Serves as an effective change agent as an educator and resource for physicians and allied health staff to improve the quality and completeness of the clinical documentation

• Performs all duties and responsibilities in accordance with ethical and legal business procedures, compliant with federal and state statutes and regulations, official coding rules, guidelines and accepted standards of coding practice including appropriate clinical documentation policies