Clinical Document Improvement Specialist- 40/hrs, Day Shifts
About The Position
Serves as the primary resource to the treatment team on medical record documentation required to support accurate classification of patient severity of illness and medical complexity. The specialist applies knowledge of clinical medicine, disease management, and internal and external patient classification systems. The role also serves as a primary educator for implementation of the International Classification of Diseases, 10th Revision (ICD-10), and clarifies documentation related to quality-of-care issues. Reviews current inpatient medical records daily, abstracts relevant clinical information, and translates it into the hospital-based coding system using ICD-10. Identifies documentation improvement opportunities that support accurate DRG, severity-of-illness, and risk-of-mortality assignments and correct reporting of quality metrics. Communicates with clinical staff through various means to educate them and obtain documentation clarification.
Requirements
- Bachelor's degree in a related field, or an associate's degree in a healthcare-related field with five years of related experience; a combination of relevant education and experience may be considered in lieu of a degree.
- Two years of experience in patient care or coding in an inpatient medical setting.
- Extensive knowledge of clinical medicine, disease management, and internal and external patient classification systems.
Nice To Haves
- Five years of experience in inpatient acute care.
- Certified Coding Specialist certification.
- Pennsylvania Practical Nurse license.
- Pennsylvania Registered Nurse license.
- Multistate Compact RN license.
Responsibilities
- Serve as the primary resource to the treatment team on medical record documentation supporting accurate classification of patient severity of illness and medical complexity.
- Educate staff on implementation of the ICD-10 classification system.
- Clarify documentation regarding quality-of-care issues.
- Review current inpatient medical records daily, abstract pertinent clinical information, and translate it into the hospital-based coding system using ICD-10.
- Identify documentation improvement opportunities to support accurate DRG, severity-of-illness, and risk-of-mortality assignments and correct reporting of quality metrics.
- Communicate with clinical staff to provide education and obtain documentation clarification.
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What This Job Offers
Job Type
Full-time
