Job Description
Role Description
- This position is expected to assist medical staff providers with documentation in the medical record.
- Review physician documentation daily
- Keep track of patient diagnosis and procedures to reflect the level of service provided
- Work independently and develop, schedule, and prioritize the workload
- Assist with coverage issues and collaborate with other reviewers and HIM coders
- Communicate effectively with physicians and staff to ensure clinical information is accurate
- Address clinical documentation issues and regulatory requirements
- Obtain medical staff cooperation assertively and tactfully
- Qualifications
- Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelor's degree with 2 years CDI experience required
- Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years of employment as Clinical Documentation Specialist (CDS)
- Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes, and related procedures required
- Up-to-date clinical skills and current working knowledge of pathology and pharmacology impacts on care required
- Experience with database, spreadsheet, and word processing required
- Detail and results-oriented, with the ability to maintain accurate, detailed, and organized records essential
- Requirements
- 5 years experience in critical care (CCU, ICU) preferred
- Benefits
- Comprehensive benefits package including medical, dental, vision, short-term and long-term disability, group term life insurance, and other optional voluntary benefits
- Employee Wellness rewards program with opportunities to enhance health and well-being
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