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Clinical Documentation Specialist

1 month ago

Nashville, Tennessee, United States ArchWell Health Full time
Job Summary

ArchWell Health is seeking a skilled Clinical Documentation Improvement Specialist to join our team. As a key member of our clinical shared services team, you will play a critical role in ensuring the accuracy and completeness of clinical documentation within our patient electronic medical records.

Key Responsibilities
  • Conduct concurrent, prospective, and retrospective medical record reviews to identify potential gaps in clinical documentation.
  • Provide ongoing feedback to physicians and other providers regarding coding guidelines and requirements.
  • Assist with education of physicians, other providers, and clinic staff relating to clinical documentation compliance and new policies and procedures related to coding.
  • Maintain competence related to HCC documentation requirements, ICD-10-CM code assignment, and coding guidelines.
  • Ensure documentation in the medical record follows official coding guidelines and internal guidelines.
  • Create and analyze reports for documentation improvement trending and high-level dashboards for ongoing monitoring and opportunities.
Requirements
  • Bachelor's degree in Nursing (BSN)
  • Three (3) years direct clinical nursing experience
  • Previous CDI experience highly desirable
What We Offer

ArchWell Health is an equal opportunity employer. We offer a competitive salary and a collaborative work environment that values innovation and teamwork.