Clinical Records Specialist

2 weeks ago


Bismarck, North Dakota, United States Insight Global Full time

Position Overview:

Insight Global is in search of a Clinical Documentation Specialist to join a prominent healthcare organization. The primary responsibility of the CDI Specialist involves the meticulous review of medical records to guarantee precise documentation by physicians, which supports the appropriate assessment of illness severity, mortality risk, and care complexity.

Key Responsibilities:

  • Conduct initial and follow-up evaluations of patient records.
  • Formulate queries directed at physicians to clarify documentation.
  • Collaborate effectively with case managers and nursing personnel.
  • Stay updated with current coding standards and engage in ongoing professional development.
  • Assist in the training of new staff members within the department.
  • Communicate CDI activities and address coding issues for resolution.

Qualifications:

The ideal candidate will possess:

  • An active State Registered Nursing License.
  • A minimum of 2 years of nursing experience.
  • Comprehensive knowledge of medical coding guidelines.

Preferred Qualifications:

Additional skills that would be advantageous include:

  • Experience in Acute Care Nursing.
  • CDIP or CCDS Certification.

This role demands a robust understanding of Medicare, disease pathophysiology, and MS-DRG classification.



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