We have other current jobs related to this field that you can find below
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Clinical Documentation Improvement Specialist
2 weeks ago
Columbus, OH, United States The Ohio State University Wexner Medical Center Full timeThis is an hybrid position. Depending on performance and the onboarding process, hybrid work can be possible after 6 months to 1 year of employment. Hybrid does not guarantee a specific set of remote days (consistent days), meaning CDI work schedules are based on business operations.Job DescriptionThe Clinical Documentation Improvement Specialist (CDIS) is a...
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Staten Island, NY, United States Clinical Management Consultants Full timeAre you an experienced and driven RN or healthcare professional looking for an exciting leadership CDI opportunity? This New York Hospital is seeking a highly qualified Manager of Clinical Documentation Improvement (CDI) to join our dynamic team. As the Manager of CDI, you will play a vital role in optimizing patient care, revenue integrity, and compliance...
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Clinical Document Improve Specialist RN
3 weeks ago
Jacksonville, FL, United States Saint Vincent's Medical Center Riverside Full timeClinical Document Improve Specialist RNDetails * Department: Total Quality Management * Schedule: Full-Time; Days; Monday - Friday 8am-4:30pm * Hospital: Ascension St. Vincents Riverside * Location: Jacksonville, Florida * CDI experience Benefits Paid time off (PTO) Various health insurance options & wellness plans Retirement benefits including employer...
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Clinical Documentation Specialist RN
3 months ago
Naples, FL, United States Physicians Regional - Pine Ridge Full timeClinical Documentation Specialist RNJob Description This position is 100% onsite, to allow for better communication and coordination with our staff and providers. The Clinical Documentation Specialist (CDS) performs clinical documentation improvement activities in an effort to support accuracy and quality of the patient records and to ensure that coded...
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Clinical Documentation Improvement Specialist
2 months ago
Chicago, IL, United States Navient Full timeAbout Xtend HealthcareXtend Healthcare is a revenue cycle management company focused exclusively on the healthcare industry. The company's services range from full revenue cycle outsourcing, A/R legacy cleanup and extended business office to coding and consulting engagements. As part of Navient (Nasdaq: NAVI), Xtend taps the strength and scale of a...
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Clinical Documentation Improvement Specialist
4 weeks ago
Chicago, IL, United States Navient Full timeAbout Xtend Healthcare Xtend Healthcare is a revenue cycle management company focused exclusively on the healthcare industry. The company's services range from full revenue cycle outsourcing, A/R legacy cleanup and extended business office to coding and consulting engagements. As part of Navient (Nasdaq: NAVI), Xtend taps the strength and scale of a...
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Berlin, MD, United States Clinical Management Consultants Full timeA fantastic career opportunity for a Clinical Documentation Improvement Assistant Director is now available at the patient-centered hospital in Southern Delaware. This hospital is a healthcare leader in the Mid-Atlantic Regina and Delaware. Their recent accolades include being ranked as a high-performing" hospital in 8 specialties. They are most...
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Travel Nurse RN
3 weeks ago
Tyler, TX, United States InfiCare Health Full timeInfiCare Health is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Tyler, Texas.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: 08/27/2024Duration: 12 weeks40 hours per weekShift: 8 hours, daysEmployment Type: TravelPerks: Health Insurance including...
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RN Specialist-Clinical Documentation Improvement
3 weeks ago
Kalamazoo, MI, United States Ascension Full timeDetails Department: HIM Coding DocumentationSchedule: Full Time/Day Shift-Remote M-F no weekends or holidays with a flexible start time between 6am and 9am.Hospital: Borgess Medical CenterLocation: Kalamazoo, MIBenefits Paid time off (PTO) Various health insurance options & wellness plans Retirement benefits including employer match plans Long-term &...
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Travel Nurse RN
4 weeks ago
Pomona, CA, United States Tact Staff Full timeTact Staff is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Pomona, California.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: 08/27/2024Duration: 13 weeks36 hours per weekShift: 12 hoursEmployment Type: TravelRole: CDI Specialist ***Locals preferred...
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Travel Nurse RN
1 month ago
Pomona, CA, United States Tact Staff Full timeTact Staff is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Pomona, California.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: 08/13/2024Duration: 13 weeks36 hours per weekShift: 12 hoursEmployment Type: TravelRole: CDI Specialist ***Locals preferred...
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Newark, DE, United States ChristianaCare Full timeJob DescriptionRN Clinical Documentation SpecialistDay Shift (Hours: M-F 8 hours) Hybrid / No Weekends or Holidays!Newark, DEChristiana Care Hospital is hiring a RN Clinical Documentation Specialist for improving the overall quality and completeness of clinical documentation within the inpatient medical record. This is a hybrid position with remote and...
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Clinical Documentation Specialist
1 month ago
Kennewick, WA, United States Trios Health Full timeJob DescriptionClinical Documentation Specialist coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation. Captures clinical severity which is later translated into coded data to support the level of service rendered...
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Clinical Documentation Specialist
1 month ago
Kennewick, WA, United States Trios Health Full timeClinical Documentation Specialist coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation. Captures clinical severity which is later translated into coded data to support the level of service rendered to relevant...
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Clinical Documentation Specialist
2 weeks ago
Kennewick, WA, United States Trios Health Full timeClinical Documentation Specialist coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation. Captures clinical severity which is later translated into coded data to support the level of service rendered to relevant...
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Travel Nurse RN
1 month ago
Phoenix, AZ, United States TotalMed Staffing Full timeTotalMed Staffing is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Phoenix, Arizona.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: ASAPDuration: 26 weeks40 hours per weekShift: 8 hours, daysEmployment Type: TravelWe are seeking a CDI-Registered Nurse...
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Travel Nurse RN
2 months ago
Phoenix, AZ, United States TotalMed Staffing Full timeTotalMed Staffing is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Phoenix, Arizona.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: 08/05/2024Duration: 13 weeks40 hours per weekShift: 8 hours, daysEmployment Type: TravelWe are seeking a CDI-Coder for...
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Travel Nurse RN
1 month ago
Pomona, CA, United States TotalMed Staffing Full timeTotalMed Staffing is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Pomona, California.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: 08/01/2024Duration: 13 weeks40 hours per weekShift: 8 hours, daysEmployment Type: TravelWe are seeking a...
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Travel Nurse RN
4 weeks ago
Pomona, CA, United States TotalMed Staffing Full timeTotalMed Staffing is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Pomona, California.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: ASAPDuration: 13 weeks40 hours per weekShift: 8 hours, daysEmployment Type: TravelWe are seeking a CDI-Registered...
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Clinical Documentation Specialist
2 months ago
San Antonio, TX, United States Christus Health Full timeDescriptionSummary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment...
Clinical Documentation Improvement Specialist- RN
2 months ago
Department: Ambulatory Surgery
Hours: Full-Time M-F, Onsite at The Surgery Center Shrewsbury with travel as required within the ASC Network
Reports to: VP of Ambulatory Surgery
About our Ambulatory Surgery Centers:
With a legacy deeply rooted in outpatient imaging, Shields built upon this expertise, diversifying our healthcare portfolio to include ambulatory surgical services. 35+ years of success in healthcare has earned Shields Ambulatory Surgery Centers (Shields ASC) a leading position in the surgery center industry.
Through joint-venture partnerships with hospitals and providers, Shields leverages our value-based position and operational discipline to develop, execute and manage multi-specialty ambulatory care facilities. The ASC facilities are designed to maximize profitability for our partners while delivering critical patient-centered medical services in a very accessible location at an accessible price for patients. Shields ASC transforms the outpatient experience by providing a convenient alternative to hospital-based procedures that are more cost-effective for our partners and our patients.
About the Role:
The Clinical Documentation Improvement Specialist (CDS) is responsible for conducting extensive analysis of patient health records in order to ensure complete and accurate documentation, as well as identification of diagnosis codes to properly reflect the severity of patient illness. The CDS collaborates with physicians to advocate for clear and succinct documentation, reflecting the extent of patient care provided, and to ensure proper reimbursement.
• Assists with appropriate identification of diagnoses, conditions and/or procedures that are representative of the patient's procedure and care provided to ensure patient medical charts are complete, accurate, and coded for revenue integrity
• Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant
• Initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity and quality of patient data, and drive improvement toward quality physician documentation within the body of the medical record
• Collaborates closely with ASC Operations, coding, clinicians, medical staff, physicians, and medical office staff to improve documentation and importance of complete and accurate documentation
• Performs chart audits to review for missing, unclear, or conflicting medical record documentation, and initiate queries to physicians requesting and obtaining additional documentation within the medical record before coding and billing
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record
• Educates members of the patient care team regarding documentation opportunities and best practices to ensure accurate documentation in the medical record
• Applies diplomacy and professionalism when interacting with physicians and clinicians; especially when addressing missing or conflicting medical record information
• Investigates, evaluates, and identifies opportunities for improvement and recognizes their relative significance in the overall system
• Provides orientation for new clinical staff regarding documentation requirements as required
• Keeps current with concepts and practices through conferences, reference material and review of current literature
• Maintains confidentiality of all patient information in accordance to HIPPA policies
• Demonstrates flexibility in the face of changing work environment, adjusting work schedule accordingly
• Meets regularly with the Administrators/Nurse Managers and Clinicians, as well as medical office staff to review all paperwork and to update them regarding new documentation requirements and ensuring revenue integrity
About You:
• Bachelor’s degree in Nursing or Health Informatics preferred but not required
• 3 years of clinical coding experience within a surgical setting, preferably in Ambulatory Surgery
• Ambulatory Surgery Coder Certification (CASCC)
• Extensive background in medical terminology, anatomy and physiology
• Understanding of CCI, edis, and LMRP standards for coded charts
• Complete knowledge of Ambulatory Surgical ICD10, CPT and HCPC codes
• Comprehensive knowledge of coding/billing modifiers, implants and bundling rules
• Ability to audit clinical documentation and coded data to validate documentation supports services rendered for reimbursement and reporting purposes
• Excellent oral and written communication skills.
• Organized, able to set priorities and meet deadlines.
• Proficient computer skills
• Collaborative team play
• Knowledge of pertinent Federal, State, and local laws, codes, and regulations.
IND-ASC
NOTE: The Job Description does not encompass all work functions of this position. The incumbent will undertake tasks of lower or equivalent classification as needed, and may also engage in higher classification work for training, development, or as warranted by
