Clinical Documentation Specialist responsible for accurate medical record reviews collaborating with healthcare professionals at ProHealth Home Care. Maintaining compliance with documentation regulations in home health settings.
EP
Hybrid RN Clinical Documentation Specialist
Posted 12 hours ago
About the role
- CDI Specialist facilitating physician documentation and conducting patient record reviews. Ensuring accuracy and adherence to clinical documentation improvement standards at Ensemble Health Partners.
Responsibilities
- Facilitates and obtains appropriate physician documentation for any patient clinical condition or procedure
- Completes timely initial and concurrent reviews of the patient medical record for Diagnosis Related Group (DRG) and documentation integrity utilizing CDI Software
- Assigns working Principal diagnosis, complication and comorbidity/major complication and comorbidity (CC/MCC)
- Clarifies with providers regarding missing, unclear, unsupported or conflicting medical record documentation per regulatory guidelines
- Educates healthcare providers regarding clinical documentation improvement and documentation guidelines
- Partners with coding professionals to ensure accuracy of documentation
Requirements
- Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, or Emergency Department experience
- Excellent interpersonal skills including verbal and written communication skills
- Ability to conduct brief presentations to a variety of audiences in clinical space
- Flexibility in assignments and workloads based on team needs
- Ability to organize and present information clearly and concisely
- Excellent computer and keyboarding skills
- High degree of prioritization skills
- Licensed Registered Nurse
- Licensed Medical Doctor
- Nurse Practitioner
- Physician Assistant
- CCDS (Certified Clinical Documentation Specialist) certification
- CDIP (Certified Documentation Improvement Practitioner (CDIP))
- CRCR (Certified Revenue Cycle Representative), required within 9 months of hire
Benefits
- Bonus Incentives
- Paid Certifications
- Tuition Reimbursement
- Comprehensive Benefits
- Career Advancement
Job title
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Experience level
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Degree requirement
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