Clinical Documentation Specialist

🔥 13 hours ago

🇺🇸 United States – Remote

⏱ Part Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 10%

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Northeast Georgia Health System

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Northeast Georgia Health System is a healthcare organization dedicated to improving the health of the community it serves. With a presence that includes 5 hospitals, 6 urgent care locations, and more than 110 doctor's offices, imaging centers, cancer treatment centers, and laboratories, the system offers a comprehensive range of medical services. It provides career opportunities in various areas, including nursing, allied health, and support services, as well as residencies and fellowships for healthcare professionals. The organization is committed to its mission through adherence to core values, offering employee benefits, and engaging in community activities. With locations providing access to both metropolitan and natural amenities, it emphasizes quality of life for employees and residents in Northeast Georgia.

📋 Description

• Improve the overall quality and completeness of clinical documentation through admission and continued-stay reviews using CDMP guidelines • Facilitate modifications to clinical documentation to accurately reflect patient severity and support appropriate DRG-based reimbursement • Conduct follow-up reviews and ensure clarifications are recorded in patient medical records • Work with physicians during patient stays to obtain required documentation and provide education • Refer quality, patient safety, utilization, and medical necessity concerns to CDI leadership, nursing, case management, or Utilization Review • Write compliant, non-leading clinical documentation queries • Monitor documentation against core measure quality indicators and address non-compliance • Collaborate with physicians, nursing staff, case managers, coding staff, and CDI team members • Assign working DRGs, update DRG worksheets, and finalize diagnoses with attending physicians • Educate audiences on clinical documentation, coding, reimbursement, and performance methodologies • Analyze DRGs to improve knowledge, performance, payment recovery, cost containment, and revenue generation • Organize daily reviews, manage schedules and workloads, meet deadlines and productivity standards • Participate in special projects and perform other assigned duties

🎯 Requirements

• Current RN Licensure in the State of Georgia • Associates Degree • Five (5) years in the practice of professional nursing • Demonstrates aptitude in critical care or medical-surgical nursing • Excellent observation skills, analytical thinking, problem-solving abilities, and written and verbal communication • Working knowledge of DRG coding optimization strategies and clinical documentation requirements helpful • Professional interpersonal skills • Computer skills and ability to be self-directed • Familiarity with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, and coding software, preferably 3M 360 Encompass • Leadership skills • Must maintain requirements contained in Remote Agreement • Ability to read, write, reason, talk, keyboard, and drive

🏖️ Benefits

• Remote work opportunity, contingent on maintaining requirements in the Remote Agreement • Equal Opportunity Employer