[Hiring] Clinical Documentation Specialist @Atos

Role Description

Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.

• Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients.
• Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an ongoing basis.
• Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities.
• Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses – obtaining missing information via a query when necessary.

Qualifications

• Must have at least one of the following:
  • License to practice as a Registered Nurse preferred (any state)
  • Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)
• Must have all of the following:
  • 1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience
  • CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required

Requirements

• Candidate must have at least 1 year of experience with concurrent inpatient facility coding/clinical documentation improvement experience.
• Experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation.
• Ability to obtain missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided.

Benefits

• Diversity and inclusion are embedded in our DNA.
• Commitment to a fair work environment for all.
• Recognized leader in its industry across Environment, Social and Governance (ESG) criteria.