Roles & Responsibilities

MAJOR RESPONSIBILITIES

1. Maintains consistency with Administrative and Departmental policies with appropriate behavior, dress, attitude, attendance, confidentiality, professionalism, and reliability.

2. Concurrently reviews selected admissions to identify most appropriate principal and secondary diagnosis to accurately reflect the patient’s severity of illness.

3. Communicates with physicians and clinicians regarding missing, unclear or conflicting medical record documentation to clarify and obtain needed documentation.

4. Develops clinician or physician education strategies to promote complete and accurate documentation and correct negative trends.

5. Confers with Coders concurrently to ensure appropriate DRG and completeness of supporting documentation.

6. Develops tools and coordinates and performs audits for compliance.

7. Gathers and analyzes information pertinent to documentation findings and outcomes.

8. Identifies patterns and trends variance, identifying opportunities for improvement.

9. Researches literature to identify new methods in development for disease components and documentation.

10. Supports and is involved with ongoing continuing education for both associates and physicians.

11. Performs audits as directed timely and efficiently.

12. Works with Director to enhance relationships and work closely with other departments and associates.

13. Strategizes and helps implement work flow processes that will impact department metrics to also include Regional initiatives.

14. Works independently with little to no supervision.

15. Will identify areas of improvement and provide suggestions for resolutions.

16. Other duties as assigned.

Preferred Qualifications

POSITION SUMMARY

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor.Support CDI staff with education and training, reconciliation of data, provide physicians and other clinicians with education presentations.

CORE COMPETENCIES

Action oriented - Taking on new opportunities and tough challenges with a sense of urgency, high energy, and enthusiasm.

Customer focus- Building strong customer relationships and delivering customer-centric solutions.

Communicates effectively- Developing and delivering multi-mode communications that

convey a clear understanding of the unique needs of different audiences.

Optimizes work processes- Knowing the most effective and efficient processes to get things

done, with a focus on continuous improvement.

Builds effective teams- Building strong-identity teams that apply their diverse skills and

perspectives to achieve common goals.

Develops talent - Developing people to meet both their career goals and the organization’s

goals.

Ensures accountability- Holding self and others accountable to meet commitments.

Minimum Qualifications

​REQUIRED EDUCATION/CERTIFICATION RHIA/RHIT/Cert. Coder

​(Associates Degree in HIM required; Bachelor’s degree in HIM highly preferred) or Current TX (or compact)

RN license (ADN req'd, BSN highly pref'd) at time of submission CDIP or CCDS CCS (Preferred)​

Required Skills

Clinical Documentation Specialist

Job Type: Contract

Schedule:

• 8 hour shift
• Monday to Friday

Education:

• Associate (Required)

Experience:

• hospital inpatient coding: 3 years (Required)
• Health information management: 3 years (Required)

License/Certification:

• RHIA/RHIT/Cert. Coder (Required)
• RN License (Required)

Ability to Commute:

• Remote (Required)

Work Location: Remote