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Role Description
This position is expected to assist medical staff providers with documentation in the medical record.
• Review physician documentation daily
• Keep track of patient diagnosis and procedures to reflect the level of service provided
• Work independently and develop, schedule, and prioritize the workload
• Assist with coverage issues and collaborate with other reviewers and HIM coders
• Communicate effectively with physicians and staff to ensure clinical information is accurate
• Address clinical documentation issues and regulatory requirements
• Obtain medical staff cooperation assertively and tactfully
Qualifications
• Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelor's degree with 2 years CDI experience required
• Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years of employment as Clinical Documentation Specialist (CDS)
• Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes, and related procedures required
• Up-to-date clinical skills and current working knowledge of pathology and pharmacology impacts on care required
• Experience with database, spreadsheet, and word processing required
• Detail and results-oriented, with the ability to maintain accurate, detailed, and organized records essential
Requirements
• 5 years experience in critical care (CCU, ICU) preferred
Benefits
• Comprehensive benefits package including medical, dental, vision, short-term and long-term disability, group term life insurance, and other optional voluntary benefits
• Employee Wellness rewards program with opportunities to enhance health and well-being