Clinical Documentation Specialist
About The Position
Overview Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Knowledge of age-specific patient needs and the elements of disease processes and related procedures. Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers. Responsibilities Provides concurrent and retrospective review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Key responsibility will be to review the chart for information not currently in the chart but that is indicated by clinical indicators in the record. Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.
Requirements
- MD; MBBS or any equivalent degree, policy requirement.
- Bachelor's degree require.
Nice To Haves
- Current MD/MBBS CDI/Coding experience preferred, but not required
Responsibilities
- Provides concurrent and retrospective review of the clinical documentation in the medical record
- Reviews the medical record with a clinical lens to identify any missing or understated diagnoses
- Reviews the chart for information not currently in the chart but that is indicated by clinical indicators in the record
- Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan
- Performs a thorough chart review to determine the appropriate principal diagnosis of the patient
- Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.
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What This Job Offers
Job Type
Full-time
Number of Employees
1,001-5,000 employees
