[Hiring] Clinical Documentation Specialist @Managed Resources

Role Description

Our Clinical Documentation Improvement (CDI) services consist of supporting the clinical validation component of the documentation and coding process. Our team members review medical record documentation and apply clinical criteria and guidelines to ensure comprehensive documentation of patient care, quality of care metrics, risk of mortality/severity of illness indicators, reduce clinical denials, and correct reimbursement. Our goal is to support clients in achieving access to care for patients and appropriate utilization of resources.

As a Clinical Documentation Specialist, you'll help ensure the medical record accurately reflects the patient's clinical condition while supporting compliance, reducing denials, improving quality metrics, and strengthening revenue cycle performance.

Qualifications

• RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), CCS (Certified Coding Specialist) credential or RN (Registered Nurse) or MD graduate/educated in foreign country – Required.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) - Required.
• Three (3) or more years of adult inpatient clinical documentation integrity experience - Required.
• Knowledge of current coding guidelines and methodologies, MSDRG, APR-DRG, HCCs; ICD-10-CM/PCS coding guidelines and conventions.
• Excellent verbal and written communication skills.
• Skill in abstracting and interpreting medical information from patient records.
• Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology and ancillary test results.

Requirements

• Conduct initial, concurrent and retrospective reviews to identify unclear, ambiguous or inconsistent documentation.
• Initiate compliant written physician queries and conduct follow up.
• Advise clinicians on the value of reliable, precise, complete, consistent, clear and timely documentation.
• Advise clinicians on the impacts of quality documentation on patient care and clinical data collection.
• Collaborate with coding staff on retrospective medical record review for severity, accuracy and quality issues.
• Follow each query through to closure including complete documentation of ongoing follow up activities and communication.
• Assist with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause.
• Track and trend documentation integrity metrics.
• Assign “working” values for severity, risk of mortality and Diagnosis related group DRG (Medical Severity and All Patients Refined) and track potential changes with documentation improvement.
• Assure record consistency among admission order, record description of medical necessity and patient status and communicate trends/findings to utilization review/case management partners.
• Function as a subject matter expert source for information regarding the impact of documentation on patient care, quality metrics and Hierarchical Condition Categories (HCCs).

Benefits

• Medical, Dental, and Vision Insurance
• Phone and Internet Stipend
• Company-Paid Life Insurance
• 401(k) Retirement Plan with Company Match
• Paid Time Off
• Seven Company-Observed Holidays
• Two Floating Holidays for Personal Observance
• Professional Development Opportunities
• Employee Recognition Programs
• Remote Work Environment