CDI - Clinical Documentation Specialist - PRN/Scheduled As Needed

Job Summary :

Job Description

Essential Responsibilities:

• Facilitates appropriate clinical diagnoses are captured as clinically support by the chart's documentation, labs, tests and other documentation.
• Ensures the accuracy and completeness of clinical information used for measuring physician and facility outcomes
• May assist in developing ICD-10 compliant query scripting for the Coding & CDI programs.
• Provides on-site or webinar-based support and clinical education as necessary.
• Reviews patient's clinical findings with Coding or Quality staff as necessary.
• Identifies learning opportunities for multidisciplinary staff as it relates to the most accurate documentation reflected in the patient's chart.
• Conducts initial and follow up reviews on patient charts as assigned by the EHR system.
• Maintains professional competencies as required by professional associations.
• Maintains a dynamic and professional communication with providers, coders, quality and other staff members.
• Adheres to the professional standards of ethical coding.
• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the associate for this job. Duties, responsibilities and activities may change at any time with or without notice. 

 

Education/Experience:

• Associate's Degree; preferably in a health care field
• 1-2 years of experience of inpatient coding in an acute care hospital setting
• 1-2 years working in an inpatient setting as a Clinical Documental Specialist

Licenses or Certifications:

• Registered Nurse (RN) or Registered Health Information Technician (RHIT)

Work Shift :

Day Shift (United States of America)

Scheduled Weekly Hours :

0