Postal Code

80210

Job Description

• Reviews concurrent medical records for compliance, completeness, and accuracy regarding severity of illness (SOI), risk of mortality (ROM), and quality.
• Completes accurate and timely record reviews to ensure the integrity of documentation compliance.
• Inputs data accurately into software, resulting in precise metrics obtained through the reconciliation process.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to clinical team members.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff.
• Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation.
• Collaborates with staff to resolve discrepancies with assignments and other coding issues. Conducts well-timed follow-up case reviews on all concurrent cases, prioritizing those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities. Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.
• Maintains a 95% physician response rate to all valid clarifications.
• Performs other duties as assigned.

Knowledge, Skills, and Abilities

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations [Required]
• Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills [Required]
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist [Required]
• Dependable, self-motivated and pleasant [Required]
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills [Required]
• Knowledge of pathophysiology, disease processes and treatments [Required]
• Strong ability to organize/triage work and manage multiple priorities at once [Required]
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures [Preferred]
• Coding background [Preferred]
• Knowledge of quality guidelines [Preferred]

Education

• Bachelor's of Nursing [Preferred]
• Master's of Nursing [Preferred]

Field of Study

• completed in health service administration, business administration, system performance engineering, industrial engineering, or public health

Work Experience

• 5+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience. [Required]
• Clinical Documentation Specialist experience [Preferred]

Additional Information

• N/A

Licenses and Certifications

• Adult Acute Care Nurse Practitioner (ACNPC) [Required] OR
• Registered Nurse (RN) [Required] OR
• Advanced Practice Registered Nurse (APRN) [Required] OR
• Educational Commission for Foreign Medical Graduates (ECFMG) [Required]
• Certified Clinical Documentation Specialist (CCDS) [Preferred]

Pay Range

$36.08 - $67.11