Clinical Documentation and Compliance Specialist

Presbyterian System Services • Albuquerque, NM

1d • Onsite

About The Position

The Clinical Documentation and Compliance Specialist assists medical staff providers with documentation in the medical record. The specialist reviews physician documentation daily and tracks patient diagnoses and procedures to ensure they reflect the level of service provided. The position requires independent workload development, scheduling, and prioritization, as well as flexibility in providing coverage and collaboration with reviewers and HIM coders. The specialist communicates and works with physicians and staff to ensure clinical information is present and accurate, supporting appropriate capture of clinical severity and services rendered. The role also requires tact and assertiveness when addressing documentation issues and obtaining medical staff cooperation.

The specialist performs concurrent inpatient medical record reviews, interprets clinical information and documentation, and works with physicians, other providers, patient care staff, and HIM Coding to clarify documentation and support accurate coding, billing, and patient severity profiles. The position maintains current knowledge of applicable technical, legal, and regulatory requirements. It is based at Presbyterian Hospital in Albuquerque, New Mexico, and is full-time with a weekday Monday–Friday schedule.

Requirements

• Associate degree in Nursing and five years of clinical experience in an acute care facility, or a bachelor's degree with two years of CDI experience.
• Achieve the Certified Clinical Documentation Specialist (CCDS) credential within three years of employment as a Clinical Documentation Specialist.
• Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes, and related procedures.
• Up-to-date clinical skills and current working knowledge of the effects of pathology and pharmacology on care.
• Experience with databases, spreadsheets, and word processing.
• Strong attention to detail and results orientation, with the ability to maintain accurate, detailed, and organized records.
• Excellent communication skills and the ability to collaborate with physicians and staff.
• Ability to work independently, prioritize workload, adapt to coverage needs, and address clinical documentation issues tactfully and assertively.

Responsibilities

• Perform concurrent reviews of inpatient medical records, including assigning DRGs, identifying complications, comorbid conditions, and other co-existing conditions, and documenting findings.
• Collaborate with medical staff, nursing staff, and other patient caregivers to improve chart documentation and accurately reflect services provided and hospital and physician profiles.
• Assist physicians with documentation requirements that support medical necessity for hospital and physician billing.
• Interpret clinical information, ordered interventions, laboratory and test results, and other record content; query when necessary for supporting documentation in progress notes, consultations, history and physicals, and other records.
• Communicate with physicians and providers, verbally or through appropriate prompter or query tools, to obtain more specific principal diagnoses, comorbidities, and complications.
• Request clarification of existing medical record documentation to support patient severity of illness.
• Serve as an expert clinical resource to the HIM Coding team and collaborate to identify documentation requiring clarification to meet regulatory requirements and accurately reflect patient severity and services provided.
• Coordinate with the HIM Coding team regarding coding guideline requirements for clinical documentation.
• Collaborate with the HIM Coding team to provide information and education to physicians and other providers who do not respond to documentation prompts or queries.
• Maintain and disseminate current technical knowledge of legal and regulatory information relevant to the business area, including applicable ICD-10, CPT, HCPCS, APC, CMS, JCAHO, and Nursing Standards of Practice updates and changes.
• Organize and prioritize workload independently, assist with coverage needs, and collaborate with other reviewers and HIM coders.

Benefits

• Medical insurance
• Dental insurance
• Vision insurance
• Short-term disability insurance
• Long-term disability insurance
• Group term life insurance
• Other optional voluntary benefits
• Employee wellness rewards program with opportunities to earn gift cards through wellness activities

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree