A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
Hospital Outpatient Coding - Certified Coding Specialist (Full-time, Monday - Friday, 8am-5pm) Washington Regional Med. Ctr. - Fayetteville, AR 72703 Apply Overview Position Type Full Time Job Shift Days Education Level High School Diploma or GED Category Admissions & Billing Services Apply Description Position Summary The role of the Coding Specialist - Certified reports to the Coding Manager. This position is responsible for the application of the appropriate diagnostic and procedural codes to individual patient medical records for data retrieval, analysis and claims processing. Essential Position Responsibilities Abstract pertinent information from patient records into the appropriate computer system for statistical and billing purpose; assigns the correct ICD-CM, ICD-PCS, discharge disposition, MS-DRG group assignments and other data as applicable Coordinate with the clinical documentation and quality teams to ensure validation of Medicare Severity Diagnosis Related Group (MSDRG), patient safety indicators, and hospital acquired conditions are supported by physician documentation to support appropriate coding Works with Clinical Documentation Specialists (CDS) and physicians to identify and address documentation improvement needs that support accurate code, Risk of Mortality (ROM), Severity of Illness (SOI), and DRG assignment Query physicians if there are discrepancies in the code assignment or documentation in the electronic medical record is inadequate Remain knowledgeable of current coding guidelines, reimbursement, and reporting requirements Ensure coding accuracy rate is met as established by department goals and objectives
Qualifications Education :
High School Diploma or GED Licensure and Certifications :
RHIA, RHIT, CCS, CIC, CPC, required.
Experience :
Minimum of 6 months of coding experience, required. Minimum 2 years inpatient coding experience, preferred. Experience with Clinical Documentation Improvement programs and clinical validation, preferred. Working knowledge of quality metrics and risk adjustment coding impacts, preferred.
Work Environment:
This position will spend 80% of time sitting while performing work in a standard office environment. This position will spend 20% of time standing and/or walking while pushing, pulling, lifting, and/or carrying up to 50 lbs.
Qualifications Qualifications Education :
High School Diploma or GED Licensure and Certifications :
RHIA, RHIT, CCS, CIC, CPC, required.
Experience :
Minimum of 6 months of coding experience, required. Minimum 2 years inpatient coding experience, preferred. Experience with Clinical Documentation Improvement programs and clinical validation, preferred. Working knowledge of quality metrics and risk adjustment coding impacts, preferred.
