Clinical Documenatation

Job Description:

• ESSENTIAL FUNCTIONS :

1. Improve the overall accuracy, quality and completeness of clinical documentation and coding in support of services provided by performing reviews and audits using accepted clinical documentation guidelines.

2. Provides individual and group education for assigned clinical & administrative staff.

3. Collaborate with appropriate staff to develop, refine, and evaluate relevant aspects of clinical documentation & coding areas of the EMR to ensure maximization of the appropriate code selection.

4. Hospital Compliance Committee representative

Job Qualifications:
A. Education: Bachelors preferred, Extensive knowledge and certification in Clinical Documentation Improvement (CDI) and/or professional coding (CPC)

B. Experience: Minimum of 3 years clinical coding and documentation in a physician practice setting

C. Other Skills: Detail oriented; good problem solving skills; professional interpersonal/communication skills

• Experience of working with computers/word processing skills
• Experience or working within a specialty setting
• Good analytical and problem solving skills
• Experience of initiating, planning, evaluating and contributing to training
• Ability to communicate at all levels clearly
• Ability to express ideas clearly in writing and verbally
• Ability to prioritize and meet deadlines
• Ability to collate data
• Excellent customer care skills
• Maintenance of confidentiality
• Excellent organizational skills
• Ability to motivate others
• Billing and accounting experience desired

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