Clinical Documentation Improvement Specialist

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🔥 19 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Lake Regional Health System

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1978

🧘 Wellness

🤝 Non-profit

Wellness • Non-profit

Lake Regional Health System is a community-based regional hospital and health system headquartered in Osage Beach, Missouri, providing a broad range of medical services including emergency care, primary care clinics, surgical services (including da Vinci robotic surgery), cardiology, neurology, obstetrics and gynecology, cancer care, rehabilitation, and various outpatient and specialty clinics. The organization also operates patient resources such as a patient portal, virtual visits, education classes, a health foundation that accepts donations, volunteer programs, and community outreach and career-education initiatives.

📋 Description

• Responsible for performing concurrent reviews of patient records to ensure complete, accurate, and specific clinical documentation. • Should have a comprehensive understanding of ICD and CPT Coding Guidelines. • Responsible for clarifying conflicting, incomplete, or imprecise documentation by actively seeking answers and actively educating providers. • Work to continuously improve clinical documentation to best reflect the care provided and corresponding reimbursement. • Responsible for improving the overall quality and completeness of clinical documentation. • Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and Coding staff to support that appropriate reimbursement, clinical severity of illness, and risk of mortality is captured for the level of service rendered to all patients. • Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and practice outcomes. • Educates all members of the patient care team on an ongoing basis.

🎯 Requirements

• Must have an Associate’s degree in Healthcare, Nursing or related field, or equivalent combination of education & experience. • Must have training in medical terminology, anatomy, and physiology. • Must have training and certification in coding, or equivalent combination of education and experience. • Three to five years CDI experience preferred. • Must possess a certification; Certified Documentation Expert Inpatient (CDEI), Certified Clinical Documentation Specialist (CCDS), or Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) with coding or clinical documentation integrity experience. • In-depth knowledge of medical record content. • In-depth knowledge of coding/classification systems (ICD & CPT) and associated coding guidelines. • Experience with compliant healthcare documentation, HCC coding requirements, alternate payment models in a multi-facility, revenue cycle experience. • Basic computer skills. • Should be knowledgeable in use of coding software (encoders). • Should be knowledgeable in LDC/NCD (or how to look this up) and Quality Measures.

🏖️ Benefits

• Health insurance • 401(k) matching • Flexible working hours • Paid time off • Professional development opportunities