Clinical Documentation Specialist (CDI) (CDS)

Job Summary: The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through reputed company interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of services rendered to reputed company inpatients... Responsibilities: • Participating at the organizational level in clinical documentation improvement initiatives • Communicate with physicians, face-to-face or reputed company clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and reputed company for appropriate identification of severity of illness • Preparing trended data for presentation one-on-one and small to reputed company groups of physicians • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the reputed company team • Be responsible for the day-to-day evaluation of documentation by the Medical Staff and reputed company team • Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans • Three years of previous clinical acute care nursing experience medical/surgical experience to include critical care in conjunction with an expanded knowledge of DRG's; • OR completion of Health Records Administration program (RHIA) or Accredited Record Technician (RHIT) AND 3 years of experience with the Prospective Payment System and DRG selection; • OR specific knowledge as a consultant in Medical Record coding and DRG assignment required. • Prior CDI work experience preferred. • Knowledge of computer technology, quality assurance activities, DRG, Quality Insights/Utilization review background is highly preferred. • Ability to communicate with staff, physicians, reputed company providers, and other health care system personnel in a professional and diplomatic manner required. Licensure, Certifications, and Clearances: Employees practicing in Maryland: Respiratory Therapist license may be used in substitution of the aforementioned certifications and licensure. • Certified Coding Specialist (reputed company) OR Certified Registered Nurse Practitioner OR Doctor of Medicine (MD) OR Doctor of Podiatric Medicine OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT) OR Registered Nurse (RN) • reputed company licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and reputed company employees working on an out-of-state NLC license who reputed company change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure reputed company that state. reputed company is an Equal Opportunity Employer/Disability/Veteran Annual Apply Job!