Baltimore, Maryland
Temple, Texas
Palos Verdes Peninsula, California
Albany, New York
Posted: 21-Dec-24
Location: Dallas, Texas
Categories:
Internal Number: 24020285rxv_54_1
JOB SUMMARY
Clinical Doc Improvement Specialist 1 performs patient record reviews concurrently and/or retrospectively to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient.
Creates queries to physicians when needed to clarify ambiguous or incomplete documentation.
The Clinical Doc Improv Spec 1 should have knowledge of ICD-10, Complications/Comorbid Conditions and their role in the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality.
SALARY - WORK MODEL
100% Remote
The pay range for this position is $37.35 (entry-level qualifications) - $57.89 (highly experienced) The specific rate will depend upon the successful candidate?s specific qualifications and prior CDI experience.
ESSENTIAL FUNCTIONS OF THE ROLE
Facilitates accurate and complete documentation of medical conditions and treatment in patient records.
Performs review of record to determine complete, accurate documentation of patient condition and treatment. As appropriate, the working DRG is updated.
Promotes and obtains appropriate documentation for any clinical conditions or procedures to support the appropriate severity of illness (SOI), expected risk of mortality (ROM) and complexity of care of the patient through extensive interaction with practitioners.
Proficiently query practitioners regarding missing, unclear, or conflicting health record documentation in an effort to obtain additional documentation within the health record as needed.
Appropriately escalates provider non-responses or inappropriate responses for reconciliation.
Collaborates with Health Information Management coders and or auditors to reconcile working versus final coded DRG.
Collaborates with peers who work directly with physicians.
KEY SUCCESS FACTORS
Must have an Associate's degree in nursing or Health Information Management or Health Informatics.
Must be a Registered Nurse (RN) or Registered Health Information Technologist (RHIT)
May require one of the following certifications:
Certified Coding Specialist (CCS)
Certified Clinical Documentation Specialist (CCDS) BSW code (CCDOSCP)
Certified Clinical Documentation Specialist Outpatient (CCDS-O)
Certified Documentation Improvement Practitioner (CDIP)
Cert Professional Coder (CPC)
4 years of nursing Acute Care, Quality, or Case Management or 4 years of inpatient coding.
Knowledge of ICD-10, Complications/Comorbid Conditions and how each determines the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality
Able to determine complete, accurate and timely documentation of all conditions.
Able to obtain missing, ambiguous or incomplete information from practitioners.
Able to analyze and interpret data in order to improve documentation practices.
Able to collaboratively work with interdisciplinary teams.
Able to provide ongoing education and information to practitioners regarding documentation practices.
BENEFITS
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
QUALIFICATIONS
- EDUCATION - Associate's
- MAJOR - Nursing
- EXPERIENCE - 4 Years of Experience
- CERTIFICATION/LICENSE/REGISTRATION -
Reg Health Information Technic (RHIT), Registered Nurse (RN) or Registered Health Information Technologist (RHIT).