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CDIS - Clinical Doc Improvement Specialist
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$44 - $68 an hour
Full-time
- SUMMARY The Clinical Documentation Specialist (CDS)/Coder III is responsible conducting clinically based concurrent and retrospective reviews of inpatient medical records.
- The CDS/Coder III abstracts and codes the diagnostic and procedural information for Inpatient Services and Surgery medical records utilizing the current version of International Classifications of Diseases in accordance with regulatory agencies and hospital specific guidelines.
- The CDS/Coder III enters the coded data and other abstracted data from the medical record into the electronic information system.
- This position assumes primary responsibility for clarifying ambiguous documentation, DRG optimization with the primary role in assisting medical staff members with improving quality of documentation and serves as a mentor to all level of Coders and CDIs. Participates in chart review projects as assigned.
- Performs initial inpatient charts reviews for documentation of inpatient admission criteria and assign working DRG within 48 hours of admission, on the working days.
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