Clinical Documentation Specialist - Health Information Management (Full Time) - 7184

Responsibilities

• Ensure accurate and appropriate physician documentation in the patient medical record to support DRG assignment by the coding staff.
• Facilitate the accurate representation of the severity of illness and risk of mortality in the patient record.
• Extensively review medical records and interact with physicians, nurse practitioners, physician assistants, and HIM professionals.
• Query physicians and other clinicians to obtain additional documentation as necessary to accurately describe the patient’s condition.
• Complete chart reviews for medical necessity.
• Communicate educational information to physicians regarding clinical documentation improvement matters and the importance of accurate and complete documentation.

Qualifications

• Bachelor’s degree in Nursing or related field required.
• Current RN license in good standing.
• At least 2 years of experience in clinical documentation or related healthcare field.
• Strong knowledge of ICD-10-CM and CPT coding systems.
• Excellent communication skills, both written and verbal.
• Ability to work independently and as part of a team.