Clinical Documentation Specialist - HIM IP CDI Job Chapel Hill area,North Carolina USA,Healthcare

Description

Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well‑being of the unique communities we serve.

Summary

The Clinical Documentation Specialist will be responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinically valid, complete, and compliant. In addition, the Clinical Documentation Specialist will educate physicians, non‑physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital‑acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered.

This position reports to the Health Care System Supervisor of Clinical Documentation Integrity.

Responsibilities

Perform concurrent inpatient reviews and facilitate appropriate clinical documentation to support the severity of illness, expected risk of mortality, hospital‑acquired conditions, patient safety indicators, and complexity of care rendered to all patients. Perform outpatient reviews and facilitate appropriate clinical documentation to support the severity of illness, hierarchical condition categories, and complexity of care rendered to all patients.

Accurately assign the working MS‑DRG, ICD‑10‑CM codes, ICD‑10‑PCS codes, CPT codes, and HCPCS codes in accordance with the Official Coding Guidelines and third‑party payer, state and federal regulations. Utilize the compliant query process according to guidelines, policy, and the AHIMA Standards of Practice. Communicate and collaborate with clinical and non‑clinical staff to expedite the resolution of documentation clarification queries.

Provide effective education using tools and during rounds and meetings (as required). Support the goals of Clinical Documentation Integrity by building relationships and promoting the importance of documentation. Encourage open dialogue and respond to questions, concerns, and requests promptly.

Compliantly follow workflow processes and competently utilize software systems to ensure accurate data collection and effectiveness of the Clinical Documentation Integrity (CDI) activities for reporting outcomes.

Demonstrate responsibility for professional growth and development by actively learning and participating in the continuing education offerings provided. Maintain competence in documentation requirements, coding guidelines, and quality measures.

Other Information

Education Requirements:

Associate’s degree in Health Information Management, Nursing or related field.
Successful completion of the Clinical Documentation Specialist Proficiency Test.

Licensure/Certification Requirements:

AHIMA (American Health Information Management Association) certification
AAPC (American Academy of Professional Coders) certification
ACDIS (Association of Clinical Documentation Improvement Specialists) certification
RN (Registered Nurse) license
LPN (Licensed Practical Nurse) license
Advance Practice Provider (NP or PA) license
Medical Doctor (MD) license

Professional Experience Requirements:

For Inpatient Clinical Documentation Specialist, three (3) years of inpatient facility medical coding, acute inpatient direct patient care, or inpatient Clinical Documentation Specialist experience.
For Outpatient Clinical Documentation Specialist, three (3) years of outpatient facility medical coding, ambulatory outpatient direct patient care, or outpatient Clinical Documentation Specialist experience.

Knowledge/Skills/and Abilities Requirements:

Strong knowledge of medical record documentation requirements and coding guidelines in accordance with third‑party payer, state and federal regulations, or strong acute/ambulatory care clinical knowledge of clinical indicators, disease processes, and treatment. Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, management of multiple priorities, as well as strong presentation skills. Strong critical thinking and sound judgement in decision making.

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