Clinical Documentation Improvement Specialist

Duties:
- Organize and maintain medical records in accordance with industry standards and regulations
- Review and verify accuracy of patient information and medical documentation
- Ensure timely and accurate completion of medical forms and reports
- Collaborate with healthcare providers to ensure proper documentation and adherence to documentation standards
- Assist with discharge planning and coordination of care for patients
- Utilize electronic health record systems such as Athenahealth, Cerner, and eClinicalWorks to input and retrieve patient information
- Maintain confidentiality and security of patient records

Qualifications:
- Previous experience working in a healthcare setting, preferably in primary care or pediatrics
- Familiarity with electronic health record systems such as Athenahealth, Cerner, and eClinicalWorks
- Knowledge of medical terminology, coding, and billing practices
- Strong attention to detail and accuracy in data entry and record keeping
- Excellent organizational skills to manage multiple tasks and prioritize workload
- Ability to work independently as well as part of a team
- Understanding of discharge planning processes and coordination of care
- Familiarity with HEDIS measures is a plus
- Experience working with nursing homes or hospice care is a plusPOSITION SUMMARY

We are seeking a highly skilled Clinical Documentation Improvement Specialist to join our team at a critical access hospital. The primary responsibility of this role is to ensure that accurate and complete documentation is maintained in the medical records of our patients. The Clinical Documentation Improvement Specialist will work collaboratively with physicians, nurses, and other healthcare professionals to improve the quality and completeness of clinical documentation.

DUTIES & RESPONSIBILITIES

Review and analyze patient medical records to identify gaps or deficiencies in documentation

Collaborate with physicians and other healthcare professionals to clarify and expand documentation to accurately reflect patient acuity and severity of illness

Educate physicians and other healthcare professionals on documentation requirements, coding guidelines, and reimbursement policies

Monitor and track the progress of clinical documentation improvement efforts

Maintain up-to-date knowledge of regulations, policies, and procedures related to clinical documentation improvement and healthcare coding

Participate in multidisciplinary teams to develop and implement quality improvement initiatives

Provide ongoing feedback to physicians and other healthcare professionals regarding their documentation practices

Collaborate with coding and billing teams to ensure accurate and timely reimbursement for services provided and review proper application of medical billing codes.

Review daily census verifying stay types are correct for inpatient, observation, surgery accounts and others as deemed necessary.

QUALIFICATIONS

Bachelor's degree in Nursing, Healthcare Administration, or related field

Current license as a Registered Nurse (RN) or other relevant healthcare professional Minimum of 3 years of experience in clinical documentation improvement or related field Strong knowledge of medical terminology, anatomy, and physiology

Familiarity with ICD-10 and CPT coding guidelines

Excellent communication and interpersonal skills

Strong analytical and critical thinking skills

Ability to work independently and as part of a team

Physical Demands:

The Clinical Documentation Improvement Specialist may be required to sit or stand for extended periods of time and may need to lift or move up to 25 pounds.

Working Conditions:

This position will primarily work in an office setting, with occasional visits to patient care areas. Remote a possibility.

Salary and Benefits:

Salary will be commensurate with experience and qualifications. Our hospital offers a competitive benefits package, including health insurance, retirement plan, paid time off, and continuing education opportunities.

Please note that this job description is not exhaustive and additional duties may be assigned as needed.

Job Type: Full-time

Pay: $20.00 - $60.00 per hour

Expected hours: 40 per week

Benefits:

• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Physical setting:

• Clinic
• Hospital
• Office

Schedule:

• 8 hour shift

Work Location: In person

Salary : $20 - $60