Clinical Documentation Specialist – III, Inpatient

🕒 September 9

⚔️ Virginia, West Virginia – Remote

⚔️ Virginia – Remote ⛰️ West Virginia – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 23%

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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.

📋 Description

• Manage service line integration throughout the health system • Perform focused and second-level reviews • Assist the CDI Manager with planning, execution, and delivery of the CDI department • Design, collect, and report data supporting the System CDI Program • Collaborate on provider educational opportunities • Provide strategic management and expertise for the assigned system service line • Attend revenue integrity meetings related to the designated service line • Review focused DRGs and conduct timely second-level reviews • Identify and record principal and secondary diagnoses, procedures, and working DRGs • Conduct initial concurrent reviews and ongoing re-reviews for selected admissions • Identify documentation clarification needs and initiate physician, nurse, or patient care coordinator queries • Educate providers and staff on documentation issues, guidelines, and unanswered queries • Promote compliance with CMS, Medicare documentation, coding, and billing regulations • Assess and improve services and regulatory compliance; report results to appropriate administrative levels • Collaborate with Quality to ensure documentation meets quality initiative standards • Collect, analyze, and submit clinical documentation reports for hospital and provider outcomes • Work with Coding Specialists on documentation, provider, and query issues • Mentor and advise Level I and II CDI Specialists • May require travel

🎯 Requirements

• Certification in one of the following: Certified Documentation Integrity Practitioner (CDIP) through AHIMA; Certified Clinical Documentation Specialist (CCDS) through ACDIS; or Certified Documentation Expert Inpatient (CDEI) through AAPC • Three years of inpatient acute care coding experience OR three years of clinical RN experience in an inpatient acute care setting OR three years of clinical LPN experience in an inpatient acute care setting • Five years of experience in Clinical Documentation Integrity • Knowledge of provider healthcare compliance, revenue cycle operations, and auditing techniques • Knowledge of anatomy, physiology, and medical terminology • Proficiency in office software programs • Excellent written, verbal, and interpersonal communication skills • Analytical and problem-solving skills • Organizational and time management skills • Ability to work independently with minimal supervision • Ability to prioritize job duties and maintain accuracy during constant interruptions • Ability to meet quality and productivity standards • Ability to adapt to changes in the workplace and work assignments • Ability to sit for long periods, with visual and hearing acuity within the normal range and manual dexterity to operate computer and office equipment

🏖️ Benefits

• Full-time schedule of 40 hours per week