JOB DESCRIPTION
The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, clinical staff, and HIM coding professionals. Active participation in team meetings and education of staff in the clinical documentation Integrity program is a key role. This a remote position.
ACCOUNTABILITIES
1. Performs daily Clinical Documentation Integrity Program tasks including extensive medical record review, identification of opportunities for documentation Integrity, formulation of clarifications and effective communication with physicians and other clinical staff to obtain needed documentation.
2. Demonstrates knowledge of DRG methodologies and coding guidelines related to clinical documentation Integrity and is able to effectively apply those guidelines and identify opportunities.
3. Formulates clinically credible and complaint documentation clarifications and addresses clarifications and compliance with physicians, clinical staff and HIM coding professionals as indicated.
4. Understands and communicates differences between Medicare and payor guidelines and how they impact DRG assignment and other data reporting requirements.
5. Develops and delivers education to physicians and clinical staff related to clinical documentation Integrity.
6. Utilizes Clinical Documentation Integrity Program software and tools is able to input data accurately and generate reports.
7. Collaborates effectively with team to ensure the team accomplishes expected outcomes; demonstrates effective communication and conflict management skills.
8. Demonstrates self-direction in continued educational growth and experience.
9. Effectively manages multiple priorities and demonstrates persistence in achieving targets.
Location: Remote
Job Requirements:
Education: Associate degree in Health Information Management or related field
Skills: Strong interpersonal and communication skills required.
Years of Experience:
License: RN with active state licensure OR
Certification: RHIA/RHIT or (CDIP) Certified Documentation Integrity Professional
PREFERRED QUALIFICATIONS
Education: Bachelor of Nursing (BSN)
Skills: Ability to use various computer systems and applications preferred.
Years of Experience: Experience with acute care inpatient coding or clinical documentation Integrity preferred.
License:
Certification: (CCS) Certified Coding Specialist
ADDITIONAL EXPERIENCE/SKILLS
Must have good organizational, analytical, writing, and interpersonal skills. Must be dependable, self-directed, and pleasant. Must be comfortable discussing a patient’s clinical condition with physicians and other clinical staff and show appropriate persistence.
Must maintain continuous education and enhance knowledge in area of specialty.
Salary: $41,600-$117,832
ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact [email protected]
Equal Opportunity Employer/Drug-Free Workplace