Senior Clinical Documentation Improvement Specialist (Exempt)

Mercy Hosptial - Fort Smith, AR

Part-time - Mid Level

Fort Smith, AR

Hospitals

About the position

The Senior Clinical Documentation Improvement Specialist plays a crucial role in ensuring the integrity of medical record documentation at Mercy Hospital. This advanced position involves reviewing inpatient medical records to identify and rectify missing or incomplete documentation, collaborating with clinical providers and various departments to enhance documentation quality, and providing educational support to healthcare providers. The role is essential for maintaining compliance with healthcare regulations and improving patient care outcomes.

Responsibilities

• Conduct reviews of inpatient medical records to identify missing, vague, and/or incomplete components.
• Communicate the need for additional documentation to the appropriate clinical provider and/or coding.
• Ensure additional documentation is completed in a timely manner.
• Collaborate with departments including coding, quality, compliance, and utilization review/case management to improve documentation quality.
• Provide data reports and educational support for required documentation elements to inpatient healthcare providers.
• Assist in special projects and committees as needed.

Requirements

• Education: RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP.
• Experience: 3 years CDI experience and 1 year in nursing, inpatient coding, UM, CM, Quality, or related field.
• Demonstrated proficiency in the Clinical Documentation Specialist role.
• Excellent critical thinking skills and reading comprehension.
• Strong clinical knowledge and ability to identify diagnoses based on clinical data.
• Extensive knowledge of disease processes and clinical outcomes.
• Experience with computer programs (EXCEL, Word, PowerPoint).
• Advanced knowledge of healthcare regulations, including reimbursement and documentation requirements.

Nice-to-haves

• 3-5 years CDI experience preferred.
• CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) certification preferred.

Benefits

• Comprehensive health, vision, and dental coverage from day one.
• Paid time off (PTO).
• Tuition reimbursement.
• Employer-matched retirement funds.