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Clinical Documentation Specialist Remote / Texas Resident - Clinical Data Management
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- Minimum Qualifications:•Certified Registered Health Information Administrator (RHIA), or Technician (RHIT), or an associate degree in a health care related discipline with Certified Coding Specialist (CCS) certification, and a minimum of 3 years medical coding experience.
- Or•Registered nurse (or medical school graduate) with a minimum of 3 years inpatient clinical experience, advanced clinical expertise and an extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.
- Licenses, Registrations, or Certifications Required: RN current license or RHIA/RHIT/CCS (medical school graduates are exempt from this MQ) And Must acquire CCDS or CDIP certification within 3 years of hireJob Summary:Scope: Responsible for the overall improvement of the quality and accuracy of medical record documentation through interaction with physicians, members of the patient care team and hospital coding staff.
- Preferred Qualifications:Bachelor of Science in Nursing (BSN)CCDS or CDIP CertificationOne year CDI experience Job Duties:Concurrently review inpatient admissions to identify opportunities to clarify missing or incomplete documentation.
- Apply knowledge of inpatient ICD-10 coding guidelines and clinical documentation requirements to assign working MS-DRG.Enter review information and working MS-DRG/APR-DRG's with associated length of stay in the shared information system, and updates this information as needed to reflect any changes in patient's status, procedures and treatments.
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