Clinical Documentation Specialist

1 month ago


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

We are seeking a highly skilled Clinical Documentation Specialist to join our team at Global Force USA. This role is 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 Health Information Management (HIM) coding staff.
  • Interpret patient charts to determine whether care given was appropriate and properly documented.
  • Develop and implement clinical documentation improvement strategies to enhance quality and accuracy.
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.
  • Ability to work effectively under pressure, hold in complete confidence all information acquired from medical records and physicians, and interpret regulations and standards for others.


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