Clinical Documentation Specialist

Essential Job Functions

• Coordinates and maintains all elements of the Clinical Documentation Improvement Program in order to meet the goals and objectives of the organization and its stakeholders.

• Meet CDI program objectives, goals, and balance scorecard metrics.

• Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.

• Ensure effective communications with key stakeholders.

• Analyzes data, creates reports to meet desired outcomes.

• Identifies trends and opportunities for improvement in clinical documentation.

• Meets program quality and productivity guidelines and standards.

• Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.

• Work effectively with CDI team members to accomplish departmental goals.

• Demonstrates continued advancement in professional growth.

• Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.

Key Success Indicators/Attributes: 

• Ability to prioritize and multi-task in a multifaceted environment.
• Demonstrate strong organizational skills and be detail oriented.
• Demonstrate ability to self-motivate, set goals, and meet deadlines.
• Demonstrate mentoring and interpersonal skills. 
• Demonstrate excellent presentation, verbal, and written communication skills.

• Ability to develop and maintain relationships with key business partners by building personal credibility and trust.

• Maintains courteous and professional working relationships with employees at all levels of the organization.

• Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required.

• Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required

• Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred

   

Work Environment

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday