Clinical Documentation Specialist

Omega Healthcare Management Services • Boca Raton, FL

12d • Remote

About The Position

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.

Requirements

• 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: Epic, Iodine CDI software
• RN, BSN, or foreign medical graduate (FMG) with strong clinical background; OR RHIA/RHIT/CCS credentialed HIM professional with significant inpatient coding experience.
• 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

• Advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required
• Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred
• Bachelor’s or Master’s degree in Nursing, HIM, or related healthcare field.
• Previous experience in clinical quality, utilization management, case management, nursing, coding, or related field (e.g., physician)
• Three to five years’ experience in a Clinical Documentation Improvement Program
• Previous experience in a management or supervisory role (minimum of three years)

Responsibilities

• Coordinates and maintains all elements of the Clinical Documentation Improvement Program.
• Ensures timely, accurate, and complete documentation of clinical information.
• Analyzes data and 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.
• Works effectively with CDI team members to accomplish departmental goals.
• Demonstrates continued advancement in professional growth.
• Performs 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