Clinical Documentation Specialist II

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

📋 Description

• Initiate and conduct simultaneous documentation reviews of selected inpatient records to address suspected inadequate or conflicting conditions, diagnoses, and procedures.

• Achieve or surpass established performance standards for chart reviews and queries.

• Educate physicians, clinicians, and other relevant parties on comprehensive and clear documentation of care, including complications and co-morbidities.

• Utilize queries, face-to-face interactions, and educational programs and tools to enhance documentation accuracy.

• Act as a resource for physicians, linking ICD-10-CM coding guidelines and medical terminology to ensure precise final code assignment.

• Adhere to coding and documentation guidelines to promote compliance for both physicians and the hospital.

• Keep coding knowledge up to date and engage in educational programs and in-services.

• Conduct ongoing CDI Final Review/DRG Reconciliation and report discrepancies in DRG mismatches for secondary review.

• Handle query reconciliation and track query outcomes to identify performance improvement opportunities.

• Support the Coding Department by liaising with physicians regarding open queries and serving as a link between coding and physicians.

• Engage in inter/intra-departmental special projects focused on enhancing physician documentation accuracy.

• Collaborate with the Physician Advisor to pinpoint documentation issues, follow up on queries, and provide education to physicians.

• Uphold hospital and departmental policies, performance improvement, safety, environmental, infection control, confidentiality, and security standards.

• Take part in orientation, precepting, and mentoring of new team members.

• Carry out other related tasks as assigned.

⛳️ Requirements

• Familiarity with care delivery documentation systems and associated medical record documents.

• In-depth knowledge and understanding of MSDRGs and the OIG work plan as they pertain to accurate coding and MSDRG assignment.

• Strong written and verbal communication, critical thinking, and interpersonal skills.

• Ability to establish effective relationships with physicians, case management, nursing, coding, and hospital personnel.

• Proficiency in computer skills and familiarity with basic office equipment.

• Capability to work independently in a time-sensitive environment.

• Self-motivated, driven, and possess a positive attitude.

• Graduate of an accredited nursing school, AHIMA accredited institution, or a recognized United States/international medical school.

• 2–5 years of Clinical Documentation Specialist (CDS) experience.

• One of the following credentials is required: RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, or NP.

🏝️ Benefits

• Medical, dental, vision, and life insurance.

• 401(k) retirement savings plan with employer matching.

• Generous paid time off.

• Opportunities for career development and continuing education.

• Health savings accounts.

• Flexible spending accounts for healthcare and dependents.

• Employee Assistance Program.

• Employee discount program.

• Optional pet insurance.

• Optional legal insurance.

• Optional accident and critical illness insurance.

• Optional long-term care insurance.

• Optional benefits for elder and childcare.

• Optional auto and home insurance.