Clinical Documentation Specialist – CDI
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Job Description
Clinical Documentation Specialist ensuring integrity of clinical documentation in United States healthcare team. Utilizing advanced coding expertise and engaging with healthcare professionals for documentation quality.
Responsibilities:
- Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant.
- Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
- Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients.
- Participates in the development and delivery of education for providers and members of the healthcare team.
Requirements:
- Associate/Diploma Degree in Nursing or Health Information Technology (HIT) or Advanced degree in nursing or medical field such as MD, DO, NP/APN or PA.
- In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist.
- Preferred certification or licensure includes: Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS) Certified Documentation Improvement Professional (CDIP).
- Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.
Benefits:
- Health insurance
- 401(k) matching
- Paid time off
- Professional development opportunities
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