Clinical Documentation Specialist

About the role

Complete admission reviews and assign a working Diagnosis Related Group (DRG). Ensure the working DRG and other information are entered in the Clinical Documentation Improvement (CDI) database. Initiate and maintain interactions with physicians and mid-level providers to gather necessary information in the medical record. Collaborate with healthcare professionals to accurately reflect the severity of illness and level of services provided in the medical record and resolve any documentation issues before patient discharge. Maintain accurate records of review activities and ensure reports and outcomes of CDI efforts are valid.

Responsibilities

• Complete admission reviews and assign a working Diagnosis Related Group (DRG).
• Ensure the working DRG and other information are entered in the Clinical Documentation Improvement (CDI) 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.

Requirements

• Licensure / Certification / Registration: One or more of the following required:
• Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) 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.
• 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 Wisconsin Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date.

Preferences

• 5 or more years of nursing experience in ICU and/or Emergency Department.
• Previous Clinical Documentation Specialist experience.

Qualifications

• High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

Skills

• Strong communication and interpersonal skills.
• Knowledge of healthcare coding and documentation standards.
• Ability to work independently and as part of a team.
• Proficiency in Microsoft Office applications.

Benefits

Life at Ascension: Where purpose meets opportunity

Pay

$79,511.52 - $110,834.59 per year

Schedule

Days | Full-Time