Job Summary

Works under the direction of the Supervisor of HIM.  The incumbent will review clinical documentation to facilitate the accurate representation of severity of illness, expected risk of mortality and complexity of care by improving the quality of physician’s clinical documentation.

This work involves extensive record review and interaction with physicians, HIM/Coding professionals, nursing staff, and ambulatory billing.  The incumbent educates the patient care team on changes in documentation guidelines and/or documentation deficiencies noted.  The patient care team includes but is not limited to:  attending physicians, consultants, physician extenders, allied health practitioners, and nursing.

Regulatory Requirements Minimum Education Required: Associate’s Degree in Healthcare Administration, Nursing, Medical Records, or related field. Minimum Experience Required: 3 years experience in coding, documentation improvement, physician practice/clinic administration, or related area. Minimum Licensure/Certification Required By Law: A current CCDS or C-CDI certification is required. C PMA, CPC, or CC S-P may be substituted at the discretion of the hiring department based on relevant work history. Additional Preferred Qualifications: Bachelor’s Degree in Healthcare Administration, Nursing, Medical Records, or related field. Bachelors may substitute for up to 2 years of relevant work experience at the discretion of the hiring department. Previous clinical documentation improvement experience, coding, payer regulations, quality assurance, or related area preferred. Knowledge of DRG, IC D-9/10 and C PT coding relative to physician clinical documentation within electronic medical records preferred. Prior experience with Meditech strongly preferred. Additional certifications beyond the minimum (particularly clinical certifications such as RN, LPN, or PT) are strongly preferred. Language Skills Ability to communicate in English, both verbally and in writing. Additional languages preferred. Excellent interpersonal skills. Skills Clear understanding of the impact Clinical Documentation Improvement has on Revenue Cycle operations and financial performance. Clear understanding of anatomy, physiology, medical terminology and disease processes Clear understanding of Ethical Standards for Clinical Documentation Improvement Professionals. Excellent written, verbal communication and interpersonal skills. Ability to prioritize and manage multiple tasks simultaneously, and to effectively anticipate and respond to issues as needed in a dynamic work environment. Dedication to treating both internal and external constituents as clients and customers, maintaining a flexible customer service approach and orientation that emphasizes service satisfaction and quality. Ability to prioritize and effectively anticipate and respond to issues as they arise. A demonstrated ability to use PC based office productivity tools (e.g. Microsoft Outlook, Microsoft Excel) as necessary; general computer skills necessary to work effectively in an office environment.