Clinical Documentation Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct both concurrent and retrospective reviews of medical records.

• Provide education to clinicians to ensure that documentation accurately represents the patient's condition(s) and treatment(s).

• Address coding inquiries and play a role in the training and development of coding personnel.

• Communicate and inform providers about the importance of precise clinical documentation.

• Collaborate with healthcare professionals to guarantee accurate documentation within the medical record.

• Train Emergency Medicine providers on enhancing clinical documentation.

• Partner with coding experts to ensure the accuracy of diagnostic and procedural data.

• Review and audit medical records to ascertain correct coding and implement corrective action plans.

• Offer ongoing training that includes updates on coding and refresher topics.

• Address client inquiries and concerns related to coding.

• Assist with new client onboarding from a coding documentation perspective.

• Execute special audits as needed.

• Engage as an active team member focused on achieving high coding accuracy.

⛳️ Requirements

• A minimum of 5 years of training in coding and/or experience in chart auditing for the professional (physician) component is required, with preferred experience in coding for the facility component (hospital).

• Background as a clinical nurse or a Clinical Documentation Integrity Specialist.

• Proficient in medical terminology and clinical procedures.

• Familiarity with the workflow of the Emergency Department.

• Knowledge of payor-specific coding and reimbursement policies.

• Coding certification is mandatory.

• An associate or bachelor's degree in a healthcare-related field.

• Comprehensive understanding of CPT, ICD-10-CM, and HCPCS coding guidelines, as well as MIPS Quality Reporting.

• Experience with Excel and Word is essential.

• Outstanding oral and written communication abilities.

• Strong organizational and problem-solving skills.

• A flexible mindset: willing and able to undertake a variety of tasks.

• Capable of functioning in a team-oriented environment.

🏝️ Benefits

• Health insurance

• Retirement plans

• Paid time off

• Flexible work arrangements

• Professional development