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Clincial Documentation Improvement Specialist (#540,295,765) 

Location: worldwide (CV #540,295,765)

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Job Description
 Job Summary

Facilitates and obtains appropriate documentation for clinical conditions or procedures to support the appropriate assignment of ICD-10-CM diagnosis codes, CPT 4 procedure codes, and appropriate Evaluation and Management (E&M) level codes.

Primary Duties and Responsibilities

 In coordination with the HIMS Quality & Education Coordinator (HIMS QEC) responsible for the Clinical Documentation Improvement (CDI) initiatives in the HIMS Department.
 Responsible for the day to day evaluation of inpatient documentation in accordance with the Clinical Documentation Program requirements.
 Reviews inpatient documentation for clarity of conditions/diagnosis and procedures where inadequate or conflicting documentation exists.
 Communicates with clinical staff and initiates queries based on evaluation of clinical information when documentation needs further specificity.
 Ensures that queries are open-ended and posed to clinicians in a compliant manner and are not leading the physician towards particular answers and initiated according to the query flow process procedure.
 Partners with the Coding Technicians to ensure accuracy of coded diagnostic and procedural data and completeness of supporting documentation to determine a working and final IR-DRG based on severity of illness and/or risk of mortality.
 Ensures diagnosis and procedure codes and E&M Level codes are supported by appropriate clinical documentation and in coordination with the Coding Technicians initiates appropriate queries for accurate data collection and reimbursement.
 Routinely follows up on queries generated by the Coding Technicians and informs the Clinical Coding
 Manager when queries have reached the threshold limits for completion.
 Conducts follow-up concurrent reviews of admissions that have incomplete or missing documentation and coordinates with the appropriate clinical or medical staff to ensure the documentation is completed prior to the patient’s discharge.
 Routinely reviews appropriate reports and liaisons with Patient Billing and Patient Access to ensure that accounts are coded and final billed in accordance within mandated timeframes.
 Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
 Coordinates with Patient Billing in the appeals and claims denial process as it relates to the Clinical Coding Section.
 Works and communicates with all clinical departments and medical staff to improve documentation in the patient’s electronic medical record (EMR).
 Collaborates with the HIMS QEC in education of the patient care teams regarding specific documentation needs for appropriate reimbursement identified through concurrent and retrospective documentation reviews.
 Identifies deficiencies in documentation and provides input on the development of templates and online forms to capture documentation for appropriate patient care and billing of the patient’s account.
 Assists the HIMS Team in the qualitative and quantitative analysis of the patient’s EMR.
 Maintains confidentiality of the patient’s protected health information (PHI) in both electronic and paper formats.
 Performs other duties and participates in special projects as assigned by the HIMS Management team.

Personal Details

Rea Relloma
30 Years

Job Details

Employment Status
Full time
Type of Salary
Fixed salary
Preferred Job Location

Educational Qualifications

Highest Qualification
Bachelor's degree  (BS Nursing) from Remedios Trinidad Romualdez Medical Foundation

Professional Details

Professional Experience
5 Years
Languages known
English  (Expert)
Additional Information
AHIMA Coding Certification
(Certified Coding Specialist)

AAPC Coding Certification
(Certified Outpatient Coder)

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