Clinical Documentation Specialist – III, Inpatient

🔥 16 hours ago

⚔️ Virginia, West Virginia – Remote

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⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 10%

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Logo of WVU Medicine

WVU Medicine

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, delivery, data collection, reporting, and department projects • Collaborate with the CDI Educator/Manager on provider education • Act as a service line expert and strategically manage CDI impact • Attend revenue integrity meetings for the designated service line • Identify and record principal and secondary diagnoses and procedures, and assign working DRGs • Conduct initial concurrent reviews and ongoing re-reviews for selected admissions • Identify documentation clarification needs through audits 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, reporting results to administrative levels • Collaborate with the Quality Department on documentation standards for quality initiatives • Collect, analyze, and submit clinical documentation reports for hospital and provider outcomes • Work with Coding Specialists to resolve documentation and query issues • Mentor and advise Level I and II CDI Specialists

🎯 Requirements

• Certification in one of: 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 • Ability to work independently with minimal supervision • Ability to meet quality and productivity standards • Ability to prioritize duties and manage time effectively • Ability to adapt to changes in the workplace and work assignments • Ability to concentrate and maintain accuracy during constant interruptions • Ability to sit for long periods • Visual and hearing acuity within the normal range • Manual dexterity to operate computer and office equipment

🏖️ Benefits

• Full-time schedule of 40 hours per week • Exempt position • May require travel

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