Clinical Documentation Specialist

Role Overview

Meet CDI program objectives, goals, and balance scorecard metrics.

Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.

Ensure effective communications with key stakeholders.

Analyzes data, creates reports to meet desired outcomes.

Identifies trends and opportunities for improvement in clinical documentation.

Meets program quality and productivity guidelines and standards.

Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.

Work effectively with CDI team members to accomplish departmental goals.

Demonstrates continued advancement in professional growth.

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Minimal travel required; up to 5%

• Experience:
  
  Bachelor’s degree in healthcare field (e.g., nursing, health information management) OR equivalent combination of education/experience combined required. (One year of education equals one year of experience).
• Minimum Experience:
  
  Minimum of one to three years’ experience in clinical quality, utilization management, case management, nursing, coding, or a related field.
• Preferred Experience:
  
  Three to five years’ experience in a Clinical Documentation Improvement Program with previous experience in clinical quality, utilization management, case management, nursing, coding, or related field (e.g., physician) of which a minimum of three years’ experience is in a management or supervisory role.
• Education:
  
  Bachelor’s degree, with a healthcare related credential

None required

In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega systems set forth in "Standard Field Employee” profile.

Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law. Omega Healthcare also prohibits harassment of applicants or employees based on any of these protected categories.

Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances. If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at emp

• 5 Years of bedside Clinical Nursing experience in Adult Intensive Care Unit, Critical Care Unit, or Medical Surgery Unit.
• Active RN license in the states of IA, WI, IL, or SD or Compact US Nursing License.
• 2 Years of concurrent experience in Clinical Documentation Integrity working with Concurrent Chart Review.
• 2 Years of Epic Experience.
• 2 Years of experience writing providers queries.
• Resume must reflect all required experience.

• Experience with Nuance CDE a plus.

Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.

Ensu…