Rn Clinical Documentation Specialist

Overview

Exp 2-5 yrs

Deg Bachelors

Relo

Occasional Travel

The Clinical Documentation Specialist provides review for both facility (hospital) and professional fee (clinics) clinical documentation in medical records; provides medical records audits; educates staff members on results of audits; prepares reports for review by Senior Management and Compliance Department; queries the medical staff and other caregivers to obtain accurate and complete physician documentation for appropriate assignment of the DRG or appropriate level of professional fee services;

performs thorough chart reviews.

• Review facility (hospital) and professional fee (clinics) documentation in medical records.
• Conduct medical records audits and educate staff on audit results.
• Prepare reports for review by Senior Management and Compliance Department.
• Query medical staff and other caregivers to obtain accurate and complete physician documentation for appropriate DRG assignment or professional fee level.
• Perform thorough chart reviews.

• Minimum 2-5 years of experience in clinical documentation or related field.
• Bachelor's degree required.
• Relo and occasional travel as needed.
• CDIS Certification (preferred).
• Current Colorado RN License (or ability to obtain).
• Knowledge of coding rules and regulations.
• Working knowledge of Medicare reimbursement system and coding structure.
• Strong broad-based clinical knowledge and understanding of pathophysiology.
• Knowledge of care delivery documentation systems and related medical record documents.
• Excellent written and verbal communication skills and critical thinking skills.
• Assertive personality traits to facilitate ongoing physician communication.
• Working knowledge of inpatient admission criteria.

The ideal candidate will have significant experience in the Clinical Documentation/HIM/Coding field; enjoy working with a dedicated group of people and will be excited to live in a beautiful mountain town.

All your information will be kept confidential according to EEO guidelines.

Direct Staffing Inc