Clinical Documentation Specialist

4 weeks ago


Charleston, West Virginia, United States CAMC Health System Full time
Job Summary

Evaluate patient medical records for accurate documentation of diagnoses and ensure compliance with coding guidelines.

Key Responsibilities
  • Review inpatient medical records to identify diagnoses and surgical procedures.
  • Determine appropriate diagnostic and procedural sequencing in accordance with UHDDS guidelines.
  • Comply with HCFA's Medicare code edits.
  • Utilize Code3 Encoder/Grouper to identify opportunities for improving clinical documentation.
  • Collaborate with physicians to ensure accurate documentation of diagnoses and procedures.
  • Verify and correct data discrepancies by initiating communication with physicians and hospital personnel.
  • Participate in quality improvement initiatives.
  • Promote positive customer service and a positive work environment.
  • Assist with improving record documentation practices to support diagnostic coding assignments.
  • Collaborate with case coordinators to identify opportunities for improving clinical documentation.
Requirements
  • Bachelor's Degree in Nursing.
  • 7 years of acute care or critical care nursing experience.
  • Registered Nurse (RN) licensure.
  • Certification in Documentation Improvement Practice (CDIP) within 3 years of hire.
Work Environment

Full-time, regular position in the Document Center Building at CAMC Health System.



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