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*This is not a remote position. This is work from the Houston Office.
Job Description
A Clinical Documentation Improvement specialist (CDIS) reviews wound care, skilled
nursing facilities, long-term care, office visits, laboratory tests, and home health records
simultaneously to ensure that the clinical documentation accurately represents the
severity and quality of the patient's illness, as well as the procedures performed in
accordance with CMS and insurance policies.
Provides training and education to providers and coding staff as needed, and
communicates with physicians, clinicians, Coding and Billing Professionals, Nursing
staff and Care Management to ensure timely and accurate documentation. Additionally,
the CDI Specialist will perform focused reviews under the direction of the department
supervisor.
A monthly provider education program is conducted for new providers as well as
ongoing education for existing providers.
Analyzes all clinical documentation for opportunities for quality improvement.
Participate in clinical and medical staff meetings to ensure documentation is available to
support applicable diagnoses.
It is expected that 65 medical records will be reviewed daily with a quality rating of 98%
or greater.
Ensure that the coding and billing team receives regular training on clinical
documentation and coding.
Support one-on-one education for staff identified as having quality or productivity
deficiencies based on departmental audits. Conduct staff audits to ensure quality
indicators are met. Review findings with appropriate personnel.
Ensure workflow is optimized to maximize automated systems, assist in training new
staff, and graduate from an accredited nursing school with an AAPC or AHIMA coding
certificate is desired.
Eligibility
Certified Clinical Documentation Improvement Practitioner (CCDS/CDIP) license -
Required.
Wound care experience - Required.
Certified Coding Specialist (CCS) license – Required.
A working knowledge of healthcare reimbursement methods. An understanding of coding
conventions, CPT, Modifiers, LCD/NCD, NCCI edits, ICD 10 CM, and CMS coding and
billing policies is necessary. Ability to communicate effectively in both oral and written
form, analytical skills, ability to organize and prioritize tasks – Required.
Registered nurse or LVN - Preferred
CDIS with three (3) years of clinical experience in surgery, long-term care facilities –
Preferred
Excellent interpersonal skills to interact effectively with all levels of hospital staff,
providers, and nursing homes.
Pay - $55,000 - $80,000/ annum based on experience.
Location: 5850 San Felipe St, Houston, TX 77057, USA
Full Time
$64k-82k (estimate)
04/24/2024
06/23/2024
The job skills required for Clinical Documentation Specialist include CPT, Billing, Clinical Documentation, Communicates Effectively, etc. Having related job skills and expertise will give you an advantage when applying to be a Clinical Documentation Specialist. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by Clinical Documentation Specialist. Select any job title you are interested in and start to search job requirements.
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Quotes from people on Clinical Documentation Specialist job description and responsibilities
Finally, a good clinical documentation specialist must be able to maintain patient confidentiality.
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Clinical Documentation Specialist analyzing medical information to assist healthcare providers.
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A clinical documentation specialist, also called a medical coder or billing specialist, oversees all types of health care documents.
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At the same time, clinical documentation excellence programs should advance the quality, accuracy, and completeness of clinical documentation.
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Clinical Documentation Specialist that are structured to be effective and efficient can provide the solutions needed to achieve accurate clinical documentation that contributes to precise health care data that’s required for value-based payment methodolo
02/20/2022: Carson City, NV
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Career tips from people on Clinical Documentation Specialist jobs
Ensuring that there us proper documentation where needed
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Always strive for point-of-service documentation.
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Clinical documentation specialists gather and process these documents.
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Documentation specialists work with hospitals and alongside healthcare providers.
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Set up documentation shortcuts.
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