Role Description
Responsible for ensuring the overall quality and completeness of medical record documentation for all payor groups, all DRGβs, including MS, AP, and APR.
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Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregivers, and Health Information coding staff.
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Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
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Educates all members of the patient care team on an ongoing basis, as needed.
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Professional team player, able to communicate well with others on all levels.
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Regular electronic contacts with other personnel throughout and outside the hospital via telephone or e-mail correspondence.
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Flexible with a working knowledge of all areas of adult medicine.
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Ability to sit for very long periods of time, manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader/printer, and other office equipment.
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Adequate to perform essential functions of the job with the type of judgments and potential consequences outlined above.
Qualifications
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EPIC EHR experience.
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Clintegrity CDE software experience.
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5 years minimum experience as Clinical Documentation Specialist in an acute setting, preferably Level 1 Trauma Center.
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CDI Subject matter expert for ALL PAYORS, all DRG groups (MS-DRG, APR-DRG, AP-DRG).
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PSI/HAC/HCC (Risk adjustment coding) knowledge/experience.
Requirements
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Registered Nurse, any state. BSN or higher preferred.
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CCDS or CDIP certification.
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Coding certification: CCS or CRC.
Special Requirements
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This is a remote position. You must self-provide high-speed internet access and a phone line.
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Depending on shortages, you may be required to self-provide additional monitors (you will need to work on a minimum of 2 monitors).
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This job does not require any travel.
Salary
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Salary Min: USD $41.00
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Salary Max: USD $70.00