RN Clinical Document Specialist- AHN
About The Position
The RN Clinical Document Specialist improves the quality and completeness of medical documentation through concurrent, prospective, and retrospective medical record review. The role works extensively with physicians, nursing staff, case managers, other patient caregivers, and medical records coding staff to support accurate documentation, appropriate reimbursement for the level of service rendered, and reliable clinical information for measuring and reporting physician and hospital outcomes. The specialist also provides ongoing education to members of the patient care team. This is primarily a remote, work-from-home role. Qualified candidates must live within 50 miles of the Greater Pittsburgh or Greater Erie regions. The role is subject to company compliance, confidentiality, HIPAA, information security, and Code of Business Conduct requirements.
Requirements
- High school diploma or GED.
- Bachelor's degree in Nursing, or relevant experience and/or education as determined by the company in lieu of a bachelor's degree.
- Five years of experience in a nursing role.
- Current Pennsylvania RN licensure or current multistate licensure through the enhanced Nurse Licensure Compact (eNLC).
Nice To Haves
- Experience in Clinical Documentation Integrity (CDI).
- Experience in coding.
- Knowledge of ICD-10 and HCC coding guidelines.
- Knowledge of the Epic electronic medical record.
- Knowledge of the 3M 360 Encompass Encoder.
- Excellent communication skills.
- Critical thinking skills.
- Certified Coding Specialist (CCS).
- Certified Outpatient Clinical Documentation Improvement Specialist (CCDS-O).
- Certified Clinical Documentation Improvement Specialist (CCDS).
- Certified Clinical Documentation Improvement Professional (CDIP).
Responsibilities
- Facilitate appropriate clinical documentation through concurrent, prospective, and retrospective medical record review.
- Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff, using knowledge of coding and HCC guidelines, documentation strategies, and clinical documentation requirements.
- Work collaboratively with coding professionals to ensure documentation of diagnoses and comorbidities completely reflects the patient's clinical status and care.
- Formulate credible clinical documentation clarifications to improve clinical documentation.
- Educate internal customers on compliant documentation responsibilities, coding and reimbursement issues, and performance improvement methodologies.
- Perform other duties as assigned or required.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
