Healthcare Documentation Expert

7 days ago


Staten Island, New York, United States Richmond University Medical Center Full time

Rewarding career opportunities await at Richmond University Medical Center As a Clinical Documentation Specialist, you will play a vital role in ensuring the accuracy and completeness of patient medical records.

About the Position

This is a full-time position that requires a strong understanding of clinical documentation guidelines and regulations. The successful candidate will be responsible for reviewing and editing patient medical records to ensure compliance with industry standards. The ideal candidate will have excellent analytical and communication skills, as well as the ability to work effectively in a fast-paced environment.

Duties and Responsibilities
  • Review inpatient medical records for identified payer populations on admission and throughout hospitalization
  • Analyze clinical information to identify areas within the chart for potential gaps in physician documentation
  • Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI)
  • Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff
  • Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient's clinical status and care
Required Skills and Qualifications
  • A Bachelor of Science degree in Nursing or International Medical Graduate
  • Minimum 5 years of acute care hospital experience
  • AHIMA CCA or CCS certification preferred
  • ACDIS CCDS or AHIMA CDIP certification preferred
  • Minimum 2 years of Inpatient Coding experience with ICD-10 CM/PCS
Benefits

We offer a competitive salary range of $85,000 - $90,000 per year, as well as opportunities for professional growth and development. At Richmond University Medical Center, we value our employees and strive to create a supportive work environment that promotes teamwork and collaboration.



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