Clinical Documentation Specialist - Nursing

Avita Health System•Ontario, OH

26d•Onsite

About The Position

Avita Health System is seeking a dedicated Clinical Documentation Specialist to join their Medical Records Department at the Ontario location. This role is accountable for improving the overall quality and completeness of provider-based clinical documentation in the medical record. The specialist will collaborate with treating providers to ensure documentation accurately reflects the severity of illness and level of services rendered. This involves extensive record review and interaction with physicians, case managers, and HIM coding staff to ensure appropriate reimbursement and accurate clinical information for profiling and reporting outcomes. The role also includes monitoring program results and reporting to management.

Requirements

Current RN Nursing License in the State of Ohio
ICD10, CPT AND HCPCS coding knowledge.
Knowledge of medical terminology, anatomy and physiology.

Nice To Haves

Two years of experience as a CDI specialist in a hospital setting.
CDI certification from an AHIMA- or ACDIS-approved program.

Responsibilities

Facilitate improvement in overall quality and completeness of provider-based clinical documentation in the medical record.
Collaborate with treating providers to ensure documentation accurately reflects severity of illness and level of services rendered.
Assess documentation through extensive review of the record.
Interact with physicians, case managers, and HIM coding staff to ensure appropriate reimbursement.
Ensure clinical information used in profiling and reporting outcomes is accurate.
Monitor program results and report to Manager and Director.