Clin. Documentation Specialist

Northeast Provider Solutions • Valhalla, NY

379d • $100,287 - $126,083

About The Position

The Clin. Documentation Specialist at NorthEast Provider Solutions Inc. is responsible for ensuring that patient medical records accurately reflect the level of clinical services provided. This role involves concurrent review of documentation, interaction with healthcare providers, and ensuring compliance with federal regulations to facilitate appropriate reimbursement for patient care services.

Requirements

• Minimum of three years of healthcare experience required.
• Strong medical/surgical background is essential.
• Experience with Coding/DRG, billing, auditing, and reimbursement preferred.
• Bachelor's degree in a healthcare field required.
• Active certification/license required: CDIP, CCDS, or CCS.
• Preferred certifications: RHIT/RHIA or active RN license.

Nice To Haves

• Experience with Cerner Millennium Electronic Medical Record and 3M CDI Software preferred.
• Regulatory background and DRG reimbursement knowledge preferred.

Responsibilities

• Reviews and analyzes patient medical records to ensure accurate documentation of diagnoses and procedures.
• Notifies attending physicians and staff of documentation requiring clarification.
• Conducts follow-up reviews to ensure documentation issues are addressed and recorded.
• Compiles and documents findings in a dedicated CDI database daily.
• Translates diagnostic phrases into coded form and ensures correct translation with healthcare providers.
• Maintains awareness of changes in federal and state regulations for prospective payment.
• Educates patient care team members on clinical documentation improvement.
• Serves as a resource for physicians regarding DRG, ICD-9, ICD-10, and PCS information.
• Facilitates ongoing education of staff on documentation improvement techniques.
• Assists with post-discharge medical record reviews to determine coding status.
• Completes timely retrospective reviews for unanswered queries.
• Facilitates complete discharge summaries and recommends strategies for improving record-keeping processes.
• Ensures compliance of clinical documents with federal laws regarding composition and storage.

Benefits

• Health Insurance
• Dental Insurance
• Vision Insurance
• Retirement Savings Plan
• Flexible Spending Account
• Paid Time Off
• Paid Holidays
• Tuition Reimbursement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree