Clinical Documentation Improvement Specialist

Luminis Health • Annapolis, MD

4h • $93,120 - $136,344 • Onsite

About The Position

Reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Works collaboratively with physicians, other healthcare professionals and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services. Remains aware of the continual changes in Federal and State regulations for prospective payment, keeps informed of changes in treatment modes and new procedures, and performs coding when physician documentation is vague or missing.

Requirements

• At least one of the following: Physician, Registered Nurse, Nurse Practitioner, Physician Assistant, and or a Professional Coder.
• Minimum of three-five years of health care experience required
• Working knowledge of basic computer programs and Microsoft Office Suite
• Typing; Ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
• Inpatient coding skills
• High level of interpersonal and communication skills necessary to establish rapport with physicians and other healthcare providers
• Chart review experience

Nice To Haves

• Strong medical surgical background is preferred.
• Experience with utilization management, coding/DRG, billing, auditing and various health care payers is also preferred
• Clinician preferred and or CDIP/CCDS credential.
• Electronic Medical Record and CDI Software experience is preferred
• Regulatory background and DRG reimbursement knowledge is preferred

Responsibilities

• Reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters
• Translates diagnostic phrases utilized by healthcare providers into coded form
• Interacts with the healthcare provider to ensure that the terms have been translated correctly
• Assigns the appropriate DRG after concurrent review of the medical record
• Works as a part of a coding team
• Maintains awareness of the continual changes in Federal and State regulations for prospective payment
• Keeps informed of changes in treatment modes and new procedures, and to perform coding when physician documentation is vague or missing

Benefits

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs

What This Job Offers

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