RN CLINICAL DOCUMENTATION SPECIALIST

Overview Exp 2-5 yrs Deg Bachelors Relo Occasional Travel The Clinical Documentation Specialist provides review for both facility (hospital) and professional fee (clinics) clinical documentation in medical records; provides medical records audits; educates staff members on results of audits; prepares reports for review by Senior Management and Compliance Department; queries the medical staff and other caregivers to obtain accurate and complete physician documentation for appropriate assignment of the DRG or appropriate level of professional fee services; performs thorough chart reviews. Responsibilities Review facility (hospital) and professional fee (clinics) documentation in medical records. Conduct medical records audits and educate staff on audit results. Prepare reports for review by Senior Management and Compliance Department. Query medical staff and other caregivers to obtain accurate and complete physician documentation for appropriate DRG assignment or professional fee level. Perform thorough chart reviews. Qualifications Minimum 2-5 years of experience in clinical documentation or related field. Bachelor's degree required. Relo and occasional travel as needed. CDIS Certification (preferred). Current Colorado RN License (or ability to obtain). Knowledge of coding rules and regulations. Working knowledge of Medicare reimbursement system and coding structure. Strong broad-based clinical knowledge and understanding of pathophysiology. Knowledge of care delivery documentation systems and related medical record documents. Excellent written and verbal communication skills and critical thinking skills. Assertive personality traits to facilitate ongoing physician communication. Working knowledge of inpatient admission criteria. The Ideal Candidate The ideal candidate will have significant experience in the Clinical Documentation/HIM/Coding field; enjoy working with a dedicated group of people and will be excited to live in a beautiful mountain town. Additional Information All your information will be kept confidential according to EEO guidelines. Direct Staffing Inc #J-18808-Ljbffr