Clinical Documentation Improvement Specialist

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🏈 Ohio – Remote

🏈 Ohio – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

👻 Ghost score 13%

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The Ohio State University, Main Campus

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 1870

📚 Education

Education

The Ohio State University, Main Campus is a public research university located in Columbus, Ohio. It offers a comprehensive education with a wide array of undergraduate, graduate, and professional programs. The university is engaged in numerous research initiatives and partnerships, providing opportunities for students, faculty, and industry partners to collaborate. Ohio State promotes a vibrant student life with various academic, recreational, and wellness services to support student needs. It also emphasizes community involvement and leadership development, fostering an inclusive environment on its multiple campuses across Ohio.

📋 Description

• Conduct concurrent reviews of inpatient medical records to identify opportunities to improve documentation quality. • Identify cases where diagnoses and procedures are absent, not stated in appropriate terminology, or not appropriately recorded. • Confer with appropriate caregivers regarding additional documentation requirements. • Achieve complete medical records by patient discharge. • Ensure documentation accurately reflects patients’ diagnoses, treatments and severity of illness. • Facilitate and enhance the coding and DRG assignment process. • Support documentation-quality initiatives across the Ohio State University Health System. • Improve documentation supporting the coding process, quality measures and Case Mix Index. • Assist attending physicians and other healthcare providers with patient-care documentation. • Follow The Joint Commission, Medicare, third-party payer and ICD-10-CM coding guidelines.

🎯 Requirements

• Bachelor's Degree in Nursing. • Registered Nurse. • 2 years of relevant experience required. • 2–4 years of relevant experience preferred. • Clinically qualified individual capable of concurrent review of inpatient medical records. • Knowledge of The Joint Commission, Medicare and third-party payer documentation guidelines. • Knowledge of official guidelines for assigning ICD-10-CM diagnosis and procedure codes. • Successful completion of a background check for final candidates. • A drug screen or physical may be required during the post-offer process.

🏖️ Benefits

• Medical, dental and vision coverage, with Ohio State paying a significant portion of the cost. • Paid time off, including sick and vacation time and 11 holidays. • State retirement plan or an alternative retirement plan, both with generous employer contributions. • Comprehensive benefits. • Growth opportunities.