Clinical Documentation Specialist

Omega Healthcare Management Services • Boca Raton, FL

3d • Remote

About The Position

The Clinical Documentation Specialist coordinates and maintains the elements and requirements of the Clinical Documentation Improvement Program, including staff and physician education, to ensure the highest quality of documentation in support of compliance and accurate representation of the care provided to the patient.

Requirements

• Ability to prioritize and multi-task in a multifaceted environment.
• Demonstrate strong organizational skills and be detail oriented.
• Demonstrate ability to self-motivate, set goals, and meet deadlines.
• Demonstrate mentoring and interpersonal skills.
• Demonstrate excellent presentation, verbal, and written communication skills.
• Ability to develop and maintain relationships with key business partners by building personal credibility and trust.
• Maintains courteous and professional working relationships with employees at all levels of the organization.
• Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required.
• Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required.
• Proven experience with ICD-10-CM/PCS coding, DRG assignment, and query processes.
• Familiarity with CMS Inpatient Prospective Payment System (IPPS), risk adjustment methodologies, and value-based purchasing programs.
• Windows, Excel experience.
• EHR: MedHost, Iodine CDI software
• Required: RN, BSN, or foreign medical graduate (FMG) with strong clinical background; OR RHIA/RHIT/CCS credentialed HIM professional with significant inpatient coding experience.
• One or more of the following certifications: Certified Clinical Documentation Specialist (CCDS) – ACDIS, Certified Documentation Improvement Practitioner (CDIP) – AHIMA, Certified Coding Specialist (CCS) – AHIMA
• Minimum of 3–5 years in clinical practice preferably CCU/ ICU , inpatient coding, or CDI role.

Nice To Haves

• Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred
• Preferred: Bachelor's or Master's degree in Nursing, HIM, or related healthcare field.

Responsibilities

• Coordinates and maintains all elements of the Clinical Documentation Improvement Program in order to meet the goals and objectives of the organization and its stakeholders.
• Meet CDI program objectives, goals, and balance scorecard metrics.
• Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
• Ensure effective communications with key stakeholders.
• Analyzes data, creates reports to meet desired outcomes.
• Identifies trends and opportunities for improvement in clinical documentation.
• Meets program quality and productivity guidelines and standards.
• Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.
• Work effectively with CDI team members to accomplish departmental goals.
• Demonstrates continued advancement in professional growth.
• Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level