Clinical Documentation Specialist

2 weeks ago


Valhalla, New York, United States WMC Health Full time
Job Summary

We are seeking a highly skilled Clinical Documentation Specialist to join our team at NorthEast Provider Solutions Inc. The successful candidate will be responsible for providing clinically based concurrent review of patient medical records to ensure accurate documentation of patient diagnoses and procedures.

Key Responsibilities
  • Review and analyze patient medical records to assess and procure accurate and complete documentation of patient diagnoses and procedures.
  • Notify attending physicians and house staff officers or other disciplines promptly of documentation requiring clarification.
  • Conduct follow-up reviews to ensure points of clarification have been addressed and recorded in the medical record.
  • Compile and document chart findings in dedicated CDI database on a daily basis.
  • Translate diagnostic phrases utilized by healthcare providers into coded form and interact with the healthcare provider to ensure that the terms have been translated correctly.
  • Maintain awareness of the continual changes in federal and state regulations for prospective payment.
  • Communicate with and educate members of the patient care team and clinical documentation team on an ongoing basis.
  • Serve as a resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM, ICD-9, ICD-10, and PCS information.
  • Facilitate ongoing education of staff in relation to chart documentation improvement techniques and practices.
  • Assist as necessary with review of the medical record post-discharge to determine coding status.
  • Complete timely retrospective review for unanswered queries.
  • Facilitate complete discharge summaries.
  • Recommend strategies for improving record-keeping processes.
  • Ensure all clinical documents are in compliance with federal laws in terms of composition and secure storage.
Qualifications
  • Minimum of three years of healthcare experience required, strong medical/surgical background.
  • Experience with Coding/DRG, billing, auditing, and reimbursement is preferred.
  • Clinician preferred with a CDIP/CCDS/CCS credential.
Benefits
  • Health Insurance
  • Dental
  • Vision
  • Retirement Savings Plan
  • Flexible Savings Account
  • Paid Time Off
  • Holidays
  • Tuition Reimbursement

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