Clinical Documentation Integrity Specialist

📋 Description

• Performs concurrent reviews of clinical documentation within the medical record.

• Facilitates and secures necessary physician documentation for various clinical conditions or procedures.

• Conducts daily evaluations of the medical record, including physician and clinical documentation, laboratory results, diagnostic data, and treatment plans.

• Oversees the daily assessment of documentation by the Medical Staff and healthcare team.

• Engages with physicians to address any missing, unclear, or contradictory medical record documentation.

• Collaborates with relevant healthcare team members to ensure that documentation in the medical record is both accurate and complete.

• Collects and analyzes information related to documentation findings and outcomes.

⛳️ Requirements

• An associate’s degree is required.

• A Bachelor of Science in Nursing or Registered Nurse designation is preferred.

• A minimum of five years of experience in an acute care hospital or RHIA/RHIT/CCS certification with five years of acute care inpatient coding experience is required.

• Licensed healthcare experience (RN, LPN, CRT/RRT) or completed medical school is preferred.

• Certifications such as CCP, CCDS, or CDIP are preferred.

• Exceptional verbal and written communication skills are essential.

• Strong organizational and planning abilities are required.

• Proficient in computer use, including database and spreadsheet analysis, presentation software, word processing, and Internet searching.

• Familiarity with organizational policies and procedures is necessary.

• Understanding of quality improvement theory and practices is important.

• Must possess the ability and willingness to embrace and adapt to change.

• Demonstrates self-motivation and adaptability by staying updated on CMS rules and regulations and incorporating those changes into daily practices.

• Knowledge of federal, state, and private payer regulations is essential.

🏝️ Benefits

• Paid Time Off (PTO)

• 401(k) plan

• Medical and dental insurance plans

• Comprehensive benefits package