Description

Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided

Responsible for concurrent inpatient medical record reviews for Medicare, Medicaid and all commercial payers

Requirements

Qualifications

Bachelors degree in Health Information Management, Nursing or related field

Must have one of the following credentials: - AHIMA (American Health Information Management Association) certification -  ACDIS (Association of Clinical Documentation Improvement Specialists) certification - RN (Registered Nurse) license -

For Inpatient Clinical Documentation Specialist, three (3) years of inpatient facility medical coding, acute inpatient direct patient care, or inpatient Clinical Documentation Specialist experience

Strong knowledge of medical record documentation requirements and coding guidelines in accordance with third party payer, state and federal regulations, or strong acute/ambulatory care clinical knowledge of clinical indicators, disease processes, and treatment

Must possess strong communication skills, both written and verbal

Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills

Strong critical thinking and sound judgement in decision making