Clinical Documentation Specialist - Nursing

Avita Health System•Crestline, OH

4h•Onsite

About The Position

The Clinical Documentation Specialist is accountable for facilitating improvement in the overall quality and completeness of provider-based clinical documentation within the medical record. This role involves collaborating with treating providers to ensure that documentation accurately reflects the severity of illness and the level of services rendered. The specialist will assess documentation through extensive record review and interact with physicians, case managers, and HIM coding staff to secure appropriate reimbursement and ensure the accuracy of clinical information used in profiling and reporting outcomes. Additionally, the position requires monitoring program results and reporting them to the Manager and Director.

Requirements

Current RN Nursing License in the State of Ohio
ICD10, CPT AND HCPCS coding knowledge
Knowledge of medical terminology, anatomy and physiology

Nice To Haves

Two years of experience as a CDI specialist in a hospital setting
CDI certification from an AHIMA- or ACDIS-approved program

Responsibilities

Facilitating improvement in overall quality and completeness of provider-based clinical documentation in the medical record.
Working collaboratively with treating providers to ensure documentation in the medical record accurately reflects severity of illness as well as level of services rendered.
Assessing documentation through extensive review of the record.
Interacting with physicians, case managers, and HIM coding staff to ensure appropriate reimbursement is received and clinical information utilized in profiling and reporting outcomes is accurate.
Monitoring program results and reporting to Manager and Director.