About This Role
This role involves improving the quality and completeness of clinical documentation in legal medical records, guided by clinical documentation guidelines and established policies. The specialist works to ensure appropriate reimbursement and achieve the highest level of SOI/ROM for patient services.
Responsibilities
- Facilitate necessary documentation in the medical record through extensive interaction with physicians, HIM, and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients
- Educate physicians regarding clinical documentation needs, changes to clinical documentation guidelines, and coding and reimbursement opportunities on an ongoing basis
- Apply knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities
- Monitor acute care (inpatient) medical records (concurrently) for diagnoses, treatments, and follow-up entries to validate the accuracy of patient medical record documentation and diagnoses, obtaining missing information via a query when necessary
Requirements
- Must have at least one of the following:
- License to practice as a Registered Nurse preferred (any state)
- Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), or CCS (Certified Coding Specialist)
- Must have all of the following:
- 1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience
- CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required
- At least 1 year of experience with concurrent inpatient facility coding/clinical documentation improvement experience
- Experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation, obtaining missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided