Clinical Documentation Specialist - Remote (Must have CCDS OR CDIP)
Revolution TechnologiesWaukegan, IL, United Statesjob_description.job_card.variable_days_ago
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job_description.job_card.job_descriptionMust have all of the following : Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and and highest level of SOI / ROM is achieved for the level of service rendered to all patients Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses – obtaining missing information via a query when necessary
Clinical Documentation Specialist Qualifications
- Must have at least one of the following :
o License to practice as a Registered Nurse preferred (any state)
o Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)
o 3+ years Acute Care (inpatient) and Concurrent Clinical Documentation Specialist experience
o CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required
Under limited direction and according to clinical documentation guidelines and established policies / procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.
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Clinical Documentation Specialist • Waukegan, IL, United States
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