Clinical Documentation Specialist

1 week ago


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

Global Force USA is seeking a highly motivated and detail-oriented Clinical Documentation Coordinator to join our team. This role plays a vital part in ensuring the accuracy and completeness of patient medical records, directly impacting reimbursement and clinical severity documentation.

As a Clinical Documentation Coordinator, you will collaborate closely with physicians, nurses, and other healthcare professionals to review and improve clinical documentation. Your expertise in coding structures, regulatory guidelines, and clinical terminology will be essential in ensuring compliance and optimal reimbursement practices.

Responsibilities:
  • Collaborate with healthcare providers to clarify and enhance the accuracy of patient medical records.
  • Review and analyze clinical documentation for completeness, clarity, and adherence to coding guidelines.
  • Identify opportunities for improvement in documentation practices and provide education to healthcare staff.
  • Stay abreast of changes in coding regulations, reimbursement policies, and industry best practices.
  • Maintain confidentiality of patient information and adhere to HIPAA regulations.
Qualifications:

We are seeking candidates with a strong clinical background and a passion for accuracy.

  • Option 1: 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.

Candidates must also possess relevant certifications, such as Certified Clinical Documentation Specialist (CCDS), Certified Document Improvement Practitioner (CDIP), or other applicable credentials.



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