Job Overview
Responsible for strategically facilitating and obtaining appropriate and quality physician documentation for clinical conditions or procedures to support the severity of illness, expected risk of mortality, and complexity of care. This position educates members of the patient care team regarding documentation guidelines. This role adheres to strict departmental and organizational goals, objectives, standards of performance, and policies and procedures. In addition, this position ensures quality documentation and regulatory compliance. Additionally, this role collaborates with physicians, nursing, and health information management coders.

Hours: M-F 8-5 PM
Location: Remote

Duties

• Recognizes opportunities for documentation improvement using strong critical-thinking skills and formulates clinically credible clarifications for inpatients.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff.
• Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation.
• Collaborates with health information management staff to resolve discrepancies with diagnostic assignments and other coding issues.
• Completes well-timed follow-up case reviews on all cases, prioritizing those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities.
• Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.
• Assists in new hire orientation through precepting and mentoring.
• Maintains regional productivity standards and demonstrates competence on compliance audit scores.
• Maintains a 97% physician response rate to all valid clarifications.
• Annual participation in Advanced Practice call.
• Maintains CCDS credentialing.
• Other duties as assigned.
• Reviews concurrent medical records for documentation compliance, including completeness, accuracy and quality. Inputs data accurately and concisely into assigned software, resulting in accurate metrics obtained through the reconciliation process.

Qualifications

• Knowledge, Skills, and Abilities:
• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations.
• Able to organize and present information clearly and concisely.
• Excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills.
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist.
• Dependable, self-motivated, and pleasant.
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills.
• Knowledge of pathophysiology, disease processes and treatments.
• Strong ability to organize/triage work and manage multiple priorities at once. [Required]
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures.
• Coding background.
• Knowledge of quality guidelines. [Preferred]

Education:

• Bachelor's of Nursing [Required]
• Master's [Preferred]

Field of Study:

• in healthcare related field

Work Experience:

• 5+ years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. [Required]
• 3+ years of Clinical Documentation Specialist experience [Required]

Additional Information:

• An equivalent combination of education and relevant work experience may be considered in lieu of the stated degree requirement:- BSN and 3+ years of Clinical Documentation Specialist experience OR - 4+ years of Clinical Documentation Specialist experience OR -Less than 2 years of Clinical Documentation Integrity experience and 10 years of acute care nursing experience.

Pay: $31.81 - $59.16 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Work Location: Remote