Clinical Documentation Specialist

Clarity Partners LLC • Chicago, IL

21d • $50,000 - $65,000 • Remote

About The Position

Voted one of Chicago's Best Places to Work by the Chicago Tribune for the ninth year in a row, Clarity Partners is hiring! Clarity Partners is seeking a Clinical Documentation Specialist to support an engagement with Cook County Health (CCH). In this role, you will work under limited direction and according to clinical documentation guidelines and established policies and procedures to improve the overall quality and completeness of clinical documentation in the legal medical record. You will facilitate necessary documentation through extensive interaction with physicians, HIM, and coding staff to ensure the most appropriate reimbursement and highest level of severity of illness/risk of mortality (SOI/ROM) for the level of service rendered to all patients. This position plays a critical role in ensuring the accuracy of clinical documentation and supports appropriate coding and billing for services provided. This position will report in a remote setting.

Requirements

• At least one of the following: license to practice as a Registered Nurse preferred (any state); or credentialed as an RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), or CCS (Certified Coding Specialist).
• 1 year of Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience required.
• CCDS (Certified Clinical Documentation Specialist — ACDIS) or CDIP (Certified Documentation Practitioner — AHIMA) credential required.
• Experience with concurrent inpatient facility coding/clinical documentation improvement required.
• Experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation, obtaining missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided.

Responsibilities

• Facilitate necessary documentation in the medical record through extensive interaction with physicians, HIM, and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients.
• Educate physicians regarding clinical documentation needs, changes to clinical documentation guidelines, and coding and reimbursement opportunities on an ongoing basis.
• Apply knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities.
• Perform acute care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses, obtaining missing information via a query when necessary.

What This Job Offers

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