Clinical Documentation Specialist II

🔥 0 minutes ago

🌵 Arizona – Remote

🌵 Arizona – Remote

💵 $35 - $55 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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Tenet Healthcare

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

👥 B2C

💰 $2G Post IPO debt on 2022-07

Healthcare • B2C

Tenet Healthcare is a for-profit healthcare services company that owns and/or operates hospitals and hospital programs through subsidiaries and affiliates across the United States. The company's website and materials describe acute-care hospitals, emergency centers, specialty services (including cancer centers and advanced cardiac imaging), medical office buildings, physician careers and community health networks; Tenet emphasizes compliance, community service, and clinical innovation.

📋 Description

• Initiate and perform concurrent documentation reviews of selected inpatient records to clarify suspected inadequate or conflicting conditions, diagnoses, and procedures • Meet or exceed defined performance standards for chart reviews and queries • Educate physicians, clinicians, and other involved parties on complete and clear documentation of care, including complications and co-morbidities • Use queries, face-to-face communications, and educational programs and tools to improve documentation • Serve as a physician resource linking ICD-10-CM coding guidelines and medical terminology to accurate final code assignment • Follow coding and documentation guidelines to support physician and hospital compliance • Maintain current coding knowledge and participate in educational programs and in-services • Perform ongoing CDI Final Review/DRG Reconciliation and report DRG mismatch disagreements for secondary review • Perform query reconciliation and monitor query outcomes for performance opportunities • Support the Coding Department by communicating with physicians about open queries and serving as liaison between coding and physicians • Participate in inter/intra-departmental special projects involving physician documentation accuracy • Collaborate with the Physician Advisor to identify documentation issues, query follow-up, and physician education • Maintain hospital and departmental policies, performance improvement, safety, environmental, infection control, confidentiality, and security standards • Participate in orientation, precepting, and mentoring of new team members • Perform other related tasks as assigned

🎯 Requirements

• Knowledge of care delivery documentation systems and related medical record documents • Detailed knowledge and understanding of MSDRGs and OIG work plan as related to correct coding and MSDRG assignment • Excellent written and verbal communication, critical thinking, and interpersonal skills • Ability to build effective relationships with physicians, case management, nursing, coding, and hospital staff • Computer skills and familiarity with basic office equipment • Ability to work independently in a time-oriented environment • Self-directed, motivated, and positive attitude • Graduate of an accredited school of nursing, AHIMA accredited school, or United States/international school of medicine • 2–5 years of CDS experience • One of the following required: RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, or NP

🏖️ Benefits

• Medical, dental, vision, and life insurance • 401(k) retirement savings plan with employer match • Generous paid time off • Career development and continuing education opportunities • Health savings accounts • Healthcare and dependent flexible spending accounts • Employee Assistance program • Employee discount program • Voluntary pet insurance • Voluntary legal insurance • Voluntary accident and critical illness insurance • Voluntary long term care • Voluntary elder and childcare benefits • Voluntary auto and home insurance