Clinical Documentation Specialist

UAB St. Vincent's • Birmingham, AL

1d • Remote

About The Position

This role focuses on improving the overall quality, completeness, and accuracy of medical record documentation. The specialist will complete admission reviews, assign working Diagnosis Related Groups (DRGs), and ensure this information is entered into the Clinical Documentation Improvement database. A key part of the role involves initiating and maintaining extensive interactions with physicians and mid-level providers to encourage more detailed medical record information. The specialist will collaborate with healthcare professionals to accurately reflect the severity of illness and level of services provided in the medical record, resolving physician queries and documentation issues before patient discharge. Maintaining accurate records of review activities and ensuring the validity of reports and outcomes of CDI efforts are also crucial.

Requirements

• Certified Coding Specialist (CCS) 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 Alabama Board of Nursing 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.
• High School diploma equivalency with 2 years of cumulative experience OR Associate'sdegree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

Responsibilities

• Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.
• 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

• generous paid time off
• paid parental leave
• Associate Assistance Program
• Tuition Reimbursement Program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED