Coding Clinical Documentation Specialist

Halifax Health • Daytona Beach, FL

87d

About The Position

This individual is responsible for identifying opportunities in concurrent and retrospective Inpatient clinical medical documentation to support quality, regulatory compliance, and effective coding. The CDI Specialist reviews inpatient medical records while patients are still in house (concurrent review) for proper documentation. This review includes new admissions to the facility, as well as re-reviews every two to three days until the patients are discharged. The CDIS communicates with clinicians and physicians, acting as an effective change agent and educator for physicians and allied health staff. The CDIS will also perform focused reviews at the discretion of the HIM Director or Coding Manager.

Requirements

• Currently licensed as an RN in the State of Florida.
• Associate's or Bachelor's degree from an accredited School of Nursing.
• A minimum of two years experience in nursing, utilization review/case management or other clinical area in an acute care facility.
• Experience in or knowledge of ICD-10 inpatient coding.
• Good interpersonal, organizational, analytical and prioritization skills.
• Effective written and verbal communications skills.
• One to three years progressive ICD-10 and CPT coding experience.
• Demonstrated ability to work independently with minimal supervision.
• Proficient computer skills, including Word and Excel.

Nice To Haves

• Knowledge of medical necessity criteria.
• Experience with inpatient ICD-10-CM coding.
• Familiarity with AHA 'Coding Clinic' guidelines.

Responsibilities

• Review inpatient medical records for proper documentation during concurrent review.
• Communicate with clinicians and physicians to educate and facilitate change.
• Perform focused reviews as directed by HIM Director or Coding Manager.
• Maintain and report clinical documentation improvement results to medical and clinical staff.
• Consult with physicians and clinical staff for clarification on conflicting information in medical records.
• Work with Interdisciplinary Team to ensure accurate and complete medical record documentation.
• Exhibit up-to-date knowledge of coding guidelines and research relevant materials.
• Apply critical thinking skills for process improvement opportunities.

What This Job Offers

• Industry: Religious, Grantmaking, Civic, Professional, and Similar Organizations
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees