Clinical Documentation Specialist - Health Information Svcs
About the role
As the Clinical Documentation Specialist, you will work to improve the overall quality of medical record documentation to ensure compliance with Medicare and Medicaid (CMS) guidelines and to expedite reimbursement. You will use both clinical and coding knowledge to obtain documentation through extensive interaction with physicians, nursing, other patient caregivers, Case Management and Health Information Management staff. You will also ensure that the clinical information used in measuring and reporting outcomes is complete, accurate, and that reimbursement is received for services rendered to patients with DRG-based payers. You will also educate members of the patient care team on documentation guidelines.
Responsibilities
- Improve overall quality of medical record documentation to ensure compliance with Medicare and Medicaid (CMS) guidelines
- Expedite reimbursement through documentation improvement
- Obtain documentation through extensive interaction with physicians, nursing, other patient caregivers, Case Management and Health Information Management staff
- Ensure clinical information used in measuring and reporting outcomes is complete and accurate
- Ensure reimbursement is received for services rendered to patients with DRG-based payers
- Educate members of the patient care team on documentation guidelines
Qualifications
- Bachelor's degree and/or equivalent combination of education, training and experience
- Current Hawai'i Registered Nurse License
- Five (5) years of clinical experience in an acute care setting that include inpatient bedside nursing
Preferred Qualifications
- Clinical Documentation Improvement (CDI) certification
- Experience with InterQual, Milliman or other nationally recognized Utilization Management criteria
- Experience with DRGs or inpatient ICD-10-CM/PCS coding
Pay
$127,691 - $159,619 USD per year
Schedule
Day - 8 Hours, Full Time Regular