Clin Documentation Spec III, RN & Coding Certification Required - Remote

Job Title

Clinical Documentation Specialist

Job Description

This is a remote position. You must self-provide high speed internet access. Depending on shortages, you may be required to self-provide additional monitors (you will need to work on a minimum of 2 monitors). This job does not require any travel. Responsible for ensuring the overall quality and completeness of medical record Documentation for all payor groups, all DRG's, including MS, AP, and APR. Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregiver and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis, as needed. Professional team player, able to communicate well with others on all levels. Regular electronic contacts with other personnel throughout and outside the hospital Contacts may be in by telephone or through e-mail correspondence. Flexible with a working knowledge of all areas of adult medicine. Ability to sit for very long periods of time, manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader/printer and other office equipment. Adequate to perform essential functions of the job with the type of judgments and potential consequences outlined above.

Experience Required

• EPIC EHR
• Clintegrity CDE software
• 5 years minimum experience as Clinical Documentation Specialist in an acute setting, preferably Level 1 Trauma Center.
• CDI Subject matter expert for ALL PAYORS, all DRG groups (MS-DRG, APR-DRG, AP-DRG)

PSI/HAC/HCC (Risk adjustment coding) knowledge/experience

Education Requirements

Registered Nurse, any state. BSN or higher preferred

License/Certification Requirements

• CCDS or CDIP
• Registered Nurse, any state. BSN or higher preferred
• Coding certification: CCS or CRC

Salary Min ($)

USD $40.00

Salary Max ($)

USD $64.00