Clinical Documentation Specialist

2 days ago


Las Vegas, Nevada, United States Global Force USA Full time
Job Summary

We are seeking a highly skilled Clinical Documentation Coordinator to join our team at Global Force USA. The successful candidate will be responsible for improving the overall quality and completeness of clinical documentation, ensuring accurate reimbursement and clinical severity are captured for all patients with a DRG-based payer.

Key Responsibilities
  • Facilitate modifications to clinical documentation through extensive interactions with physicians, nursing staff, and other healthcare team members.
  • Collaborate with Health Information Management (HIM) coding staff to ensure accurate and complete clinical documentation.
  • Analyze and interpret patient charts to determine whether care given was appropriate and properly documented.
  • Develop and implement strategies to improve clinical documentation quality and completeness.
  • Provide education and training to healthcare staff on clinical documentation best practices.
Requirements
  • Graduation from an accredited school of nursing and five (5) years of clinical nursing experience and three (3) years of clinical documentation improvement experience.
  • Option 2: Physician graduate International MD with 5 years of acute care experience and 1-year Clinical Documentation Improvement (CDI) experience.
  • Option 3: Equivalent to a Bachelor's degree in Health Information Management or Health Information Technology and four (4) years of professional coding and abstracting medical records in an acute care hospital.
Licensing/Certification Requirements
  • Valid license by the State of Nevada to practice as a Registered Nurse.
  • Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O), or Certified Document Improvement Practitioner (CDIP).
Knowledge, Skills, Abilities, and Physical Requirements
  • Knowledge of Medicare reimbursement system and coding structures, hospital policies and procedures, Joint Commission Accredited Health care Organizations standards, state statutes governing hospital services and health care, Medicare/Medicaid guidelines and other relevant regulations and standards.
  • Skills in working effectively under pressure, holding in complete confidence all information acquired from medical records and physicians, interpreting patient charts, and analyzing statistical and other quantitative data.
Working Conditions
  • Mobility to work in a typical office setting and use standard equipment, stamina to remain seated for extended periods of time, vision to read printed materials and a VDT screen, and hearing and speech to communicate effectively in person and over the telephone.
  • Strength and agility to exert up to 10 pounds of force occasionally and/or an eligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.


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