Clinical Documentation Specialist - Nursing
About the role
The Clinical Documentation Specialist will be accountable for improving the quality and completeness of clinical documentation in the medical record. They will collaborate with treating providers to ensure accurate documentation reflecting the severity of illness and level of services provided. The position involves reviewing records, interacting with physicians, case managers, and HIM coding staff, and monitoring program results.
Responsibilities
- Facilitate improvement in overall quality and completeness of provider-based clinical documentation in the medical record.
- Work collaboratively with treating providers to ensure documentation accurately reflects the severity of illness and level of services rendered.
- Absorb documentation through extensive review of the record and interact with physicians, case managers, and HIM coding staff to ensure appropriate reimbursement is received and clinical information utilized in profiling and reporting outcomes is accurate.
- Maintain oversight of program results and report findings to the Manager and Director.
Qualifications
- Current RN Nursing License in the State of Ohio
- ICD10, CPT AND HCPCS coding knowledge
- Knowledge of medical terminology, anatomy, and physiology
Preferred Qualifications
- Two years of experience as a CDI specialist in a hospital setting
- CDI certification from an AHIMA- or ACDIS-approved program
Pay
Competitive wages and comprehensive benefits are offered.
Schedule
Generous paid time off (PTO) to support work-life balance is provided.
Benefits
- Health, dental, and vision insurance options
- 403(b) retirement plans with up to 4% employer match
- Paid parental leave
- Pharmacy discounts for employees
- Free on-site parking
What You Can Expect at Avita
A collaborative and engaged workplace culture, competitive wages and comprehensive benefits, generous paid time off (PTO), health, dental, and vision insurance options, 403(b) retirement plans with up to 4% employer match, paid parental leave, pharmacy discounts for employees, free on-site parking, and opportunities for professional growth and internal advancement are some of the benefits offered.
Location
Avita Health System – Avita Ontario Hospital – Medical Records Department
Equal Opportunity Employer
At Avita, we are committed to creating a supportive, inclusive, and empowering environment where every team member plays a vital role in delivering exceptional care to our communities. We are an Equal Opportunity Employer.