Clinical Document Specialist

UCHealth • Cincinnati, OH

397d

About The Position

The Clinical Document Specialist plays a crucial role in enhancing the quality of clinical documentation within UC Health. This position involves collaborating with physicians to ensure that the medical records accurately reflect the level of services provided and the acuity of care. The specialist will also conduct follow-up reviews to verify that any clarifications made with physicians are properly documented and coded by the hospital's Health Information Management (HIM) Coding staff.

Requirements

• Experience in clinical documentation improvement or related field.
• Strong understanding of medical terminology and coding guidelines.
• Excellent communication and interpersonal skills.
• Ability to work collaboratively with healthcare professionals.

Nice To Haves

• Certification in Clinical Documentation Improvement (CDI) or related certification.
• Experience with electronic health record (EHR) systems.

Responsibilities

• Collaborate with physicians to improve clinical documentation accuracy.
• Conduct follow-up reviews to ensure documentation changes are recorded in the medical record.
• Work with HIM Coding staff to ensure proper coding of clinical documentation.
• Facilitate training and education for physicians on documentation best practices.

Benefits

• Health insurance coverage
• 401k retirement plan
• Paid time off
• Professional development opportunities

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Education Level: No Education Listed