Clinical Documentation (CDI) SpecialistPresbyterian Healthcare Services • Albuquerque, NM, US
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Clinical Documentation (CDI) Specialist
Presbyterian Healthcare Services • Albuquerque, NM, US
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job_description.job_card.job_descriptionAssociate's degree in Nursing and 5 years clinical experience in an acute care facility or Bachelor's degree with 2 years CDI experience required. Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS). Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes and related procedures required. Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required. Experience with database, spreadsheet and word process required. Detail and results oriented, with the ability to maintain accurate, detailed and organized records essential. Education specialization : Nursing. Responsible for clinical documentation analysis of the medical record, documentation completeness, coding accuracy and compliance in either electronic or hard copy form as designated. Performs concurrent reviews of the medical record for inpatient admissions to include assignments of DRG, identifying complication and co-morbid conditions and specific co-existing conditions and documents findings. Works collaboratively with the Medical Staff, Nursing Staff and other patient care givers to improve the quality of chart documentation to accurately reflect services provided and present an accurate hospital and physicians profile. Assist physicians with documentation requirements to support medical necessity for hospital and physician billing. Interprets clinical information in the medical record, ordered interventions, lab and test results, etc., and queries if necessary, for supporting documentation in progress notes, consultations, history and physicals, etc., as appropriate. Initiates communication to physicians, providers, verbally or utilizing the appropriate prompter / query tools, in order to obtain more specific principal diagnosis or co morbidities and complications. Acts as expert clinical resource for the HIM Coding team, working collaboratively to identify areas for clarification of documentation in the medical record that meets regulatory requirements to accurately reflect patient severity of illness and services provided. Coordinates with the HIM Coding team related to coding guideline requirements for clinical documentation. Collaborates with the HIM Coding team to provide information and education as necessary to physician and other providers not responding to prompters / queries on documentation requirements. Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. Maintains up-to-date working knowledge of all PHS coding and documentation IT applications. Maintains current knowledge of Nursing Practice through seminars, workshops, publications, etc. Conducts training classes in areas of coding, documentation and compliance for physicians and other providers. Serves as a liaison to other departments, providing clinical expertise and consultation. Utilizes monitoring tools to track defined measures for progress of documentation accuracy.
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Overview
Presbyterian is seeking a
Clinical Documentation Specialist . This position requires a proactive individual with the confidence to address documentation concerns while maintaining positive relationships with medical staff . If you're ready to make a meaningful impact in clinical documentation, we'd love to hear from you!
This role involves daily review of physician documentation, tracking patient diagnoses and procedures, and ensuring that the level of service provided is accurately reflected.
Type of Opportunity : Full Time (1.0) - Exempt : Yes. Job is based at Presbyterian Hospital. Work hours : Weekday Schedule Monday-Friday.
How You Grow, Learn And Thrive Matters Here.
- Educational and career development options, including tuition and certification reimbursement, scholarship opportunities.
- Staff Safety (A wearable badge that allows employees to quickly and discreetly call for help when safety is a concern).
- Shift differentials for nights and weekends.
- Differentials for higher education, certifications and various lead roles.
- Malpractice liability insurance.
- Loan forgiveness through the New Mexico Higher Education Department.
- EPIC electronic charting system.
Qualifications
Responsibilities
Benefits
Presbyterian offers a comprehensive benefits package to eligible employees, including medical, dental, vision, disability coverage, life insurance, and optional voluntary benefits.
About Presbyterian Healthcare Services
Presbyterian is a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan, and a growing multi-specialty medical group. AA / EOE / VET / DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
Maximum Offer for this position is up to $45.82 / Hr.
Compensation Disclaimer
The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.
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