Clinical Documentation and Compliance Specialist
About The Position
The Clinical Documentation and Compliance Specialist assists medical staff providers with documentation in the medical record. The role reviews physician documentation daily and tracks patient diagnoses and procedures to ensure the record reflects the level of service provided. The specialist works independently to develop, schedule, and prioritize workload, while remaining flexible to support coverage needs and collaborating with other reviewers and HIM coders. The position requires excellent communication skills for daily interaction with physicians and staff to ensure clinical information is present and accurate and that the patient’s clinical severity is captured appropriately. The specialist addresses clinical documentation issues and regulatory requirements with assertiveness and tact, including situations where providers may believe the record is already adequately documented. This is a full-time, exempt position based at Presbyterian Hospital in Albuquerque, New Mexico, with a weekday Monday–Friday schedule. The role performs concurrent inpatient medical-record reviews, supports providers with documentation for medical necessity and billing, and serves as a clinical resource to the HIM Coding team. Benefits-eligible employees receive a comprehensive benefits package, including medical, dental, vision, short- and long-term disability, group term life insurance, and optional voluntary benefits. The organization also offers an employee wellness rewards program.
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 CCDS (Certified Clinical Documentation Specialist) certification 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 pathology and pharmacology impacts on care.
- Experience with databases, spreadsheets, and word processing.
- Detail- and results-oriented, with the ability to maintain accurate, detailed, and organized records.
- Excellent communication skills and the ability to address documentation issues assertively and tactfully.
- Ability to work independently, prioritize workload, remain flexible to assist with coverage, and collaborate as a team member.
Responsibilities
- Perform concurrent reviews of inpatient medical records, assign DRGs, identify complications and co-morbid or co-existing conditions, and document 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, interventions, laboratory and test results, and query when needed to support documentation in progress notes, consultations, history and physicals, and other appropriate records.
- Communicate with physicians and providers verbally or through appropriate prompter/query tools to obtain more specific principal diagnoses, co-morbidities, and complications, and clarify documentation supporting patient severity of illness.
- Act as a clinical resource for the HIM Coding team and work collaboratively to identify documentation clarification needs that 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 prompters or queries.
- Maintain and disseminate current technical knowledge of legal and regulatory information relevant to the business area, including ICD-10, CPT, HCPCS, APC, CMS, JCAHO, and Nursing Standards of Practice updates and changes.
Benefits
- Medical insurance
- Dental insurance
- Vision insurance
- Short-term disability insurance
- Long-term disability insurance
- Group term life insurance
- Optional voluntary benefits
- Employee Wellness rewards program with opportunities to earn gift cards through wellness activities
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
