The Clinical Documentation Improvement Specialist II performs patient record reviews to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. The Clinical Documentation Improvement Specialist II formulates, interprets, and analyzes data relative to opportunities to improve documentation practices. The Clinical Documentation Improvement Specialist II promotes and obtains appropriate documentation for any clinical conditions or procedures to support the appropriate severity of illness (SOI), expected risk of mortality (ROM) and complexity of care of the patient through extensive interaction with practitioners. The Clinical Documentation Improvement Specialist II recommend proficient queries to practitioners or support staff regarding missing, unclear, or conflicting health record documentation in an effort to obtain additional documentation within the health record as needed. The Clinical Documentation Improvement Specialist II collaboratively works with interdisciplinary teams including, but not limited to physicians, mid-level providers, nurses, Patient Safety and Health Care Improvement. The Clinical Documentation Improvement Specialist II develops and/or provides ongoing education and information regarding documentation opportunities to practitioners, Health Information Management Coders, and other Clinical Documentation Improvement Specialists.
The ideal candidate is detail oriented with exceptional analytical and critical thinking skills, have excellent written and verbal communications skills and strong organizational skills.
Specialty/Department/Practice Clinical Documentation Improvement
Shift/Schedule Full time
Benefits Our competitive benefits package includes*:
Immediate eligibility for health and welfare benefits
401(k) savings plan with dollar-for-dollar match up to 5%
PTO accrual beginning Day 1
*Note: Benefits may vary based upon position type and/or level.QUALIFICATIONS
- EDUCATION - Bachelor's
- EXPERIENCE - A minimum of 4 years experience required
- CERTIFICATION/LICENSE/REGISTRATION -
Cert Cln Documentation Spec (CCDOCSP), Cert Coding Specialist (CCS), Cert Doc Improv Practitioner (CDIP): Must also have one of the following coding certifications:
Certified Coding Specialist orCert Clin Doc Spec orCert Doc Improvement Practitioner.
Reg Health Info Administrator (RHIA), Registered Nurse (RN): Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).