Clinical Documentation Improvement Specialist

1 week ago


Richmond, Virginia, United States Universal Health Services Full time
Job Summary

The Clinical Documentation Improvement Specialist is responsible for evaluating the appropriateness of patient charges by examining medical records, facility protocols, corporate standards, and other relevant documentation.

Key Responsibilities
  • Conduct concurrent and retrospective reviews of inpatient medical records to evaluate the utilization and documentation of acute care services.
  • Facilitate appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality.
  • Develop and coordinate educational in-services for facility staff on charging and billing issues.
  • Analyze denial trends to identify documentation and charging opportunities.
  • Act as a liaison between facility administration, the Shared Services Center, and ancillary department directors concerning charging issues, clinical documentation, and revenue opportunities.
Requirements
  • Current RN license and maintained during employment in this position.
  • At least 5 years of clinical experience in an acute care setting.
  • CCDS certification within 2 years of hire date.
  • Critical Care, Medical/Surgical or Emergency Department nursing preferred.
  • Knowledge of care delivery documentation systems and related medical record documents.
  • Knowledge of age-specific needs and the elements of disease processes and related procedures.
  • Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
  • Working knowledge of inpatient admission criteria.
  • Working knowledge of Medicare reimbursement system and coding structures preferred.
  • Assertive personality traits to facilitate ongoing physician communication.


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