Clinical Documentation Specialist
About The Position
Ascension Wisconsin Hospitals is seeking a Clinical Documentation Specialist for their Clinical Integrity Documentation department. This is a full-time, remote position with day shifts. The role involves completing admission reviews, assigning working Diagnosis Related Groups (DRGs), and ensuring accurate entry into the Clinical Documentation Improvement database. The specialist will initiate and maintain interactions with physicians and mid-level providers to enhance the detail in medical records. Collaboration with healthcare professionals is key to accurately reflecting the severity of illness and level of services provided, resolving physician queries and documentation issues before patient discharge. Maintaining accurate records of review activities and reporting on CDI efforts are also crucial responsibilities.
Requirements
- Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
- Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
- Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
- Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
- Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
- Licensed Registered Nurse credentialed from the Wisconsin Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date.
- High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.
- 5 or more years of nursing experience in ICU and/or Emergency Department
- Previous Clinical Documentation Specialist experience
Responsibilities
- Complete admission reviews and assign a working Diagnosis Related Group.
- Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.
- Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
- Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.
- Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.
Benefits
- Paid time off (PTO)
- Various health insurance options & wellness plans
- Retirement benefits including employer match plans
- Long-term & short-term disability
- Employee assistance programs (EAP)
- Parental leave & adoption assistance
- Tuition reimbursement
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
