Clinical Documentation Specialist

EAPPS TECH LLC

dba Magicforce Raleigh, NC Job Details $40

• $60 an hour 8 hours ago Qualifications Inpatient Acute care facility experience Clinical documentation improvement Clinical documentation standards Medical record review for billing accuracy Full Job Description Clinical Documentation Specialist Qualifications Must have at least one of the following: License to practice as a Registered Nurse preferred (any state) Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist) Must have all of the following: 1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience CCDS (Certified Clinical Documentation Specialist•ACDIS) or CDIP (Certified Documentation Practitioner•AHIMA) credential required Additional notes: Candidate must have at least 1 year of experience with concurrent inpatient facility coding/clinical documentation improvement experience.

We are looking for someone who has had experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation obtaining missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided. Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record. Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses

• obtaining missing information via a query when necessary