Clinical Documentation Specialist

Key attributes for success:

• Ability to clearly and effectively communicate
• Great organizational skills
• Exceptional attention to detail with excellent time management
• Critical thinker

Why choose Stillwater Medical?

• Competitive pay and excellent benefits
• Modern Healthcare's Best Places to Work - since 2012
• A Newsweek's World's Best Hospital

Details:

• One weekend day per week preferred
• Ability to work remotely
• See below for qualifications

JOB SUMMARY: The Clinical Documentation Specialist (CDS) reviews medical records upon admission and concurrently for proper documentation. The CDS queries physicians for clarification and specificity of documentation in accordance with hospital policy. Attends Medical Staff meetings as requested, provides education and training, as needed. Performs focused reviews at the discretion of the Coding Manager or Coding/CDI Director. Tracks CDI cases, queries, opportunities for improvement and practitioner response rates in software. Communicates concerns and documentation trends to Director for timely resolution. Will help to improve medical record provider documentation by performing concurrent medical record reviews and addressing incomplete documentation with physicians to ensure that case mix index, severity of illness, and risk of mortality is optimized for maximum reimbursement and risk adjustment opportunity. QUALIFICATIONS:

• Graduation from accredited RHIA or RHIT program or eligible, OR
• Graduation from a Registered Nursing Program.
• Minimum of 3-5 years coding experience preferred.
• Minimum 1-year direct CDI experience preferred.
• Nursing: Minimum 3 year of Clinical experience in Medical/Surgical preferred.
• Certified Coding Specialist (CCS) through the American Health Information Management Association OR Certified Documentation Improvement Practitioner (CDIP) eligible. If eligible, must pass a certification exam within 2 years of employment; OR
• Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Integrity Specialists (ACDIS) and/or if eligible, must pass certification within 2 years of employment.
• Understanding of Case Management principles is essential.
• Knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and reimbursement or willingness to obtain.
• Knowledge of medical record documentation practices required.
• Knowledge of medical/hospital charge processes is beneficial.
• Shall maintain active registration with the American Health Information Management Association or ACDIS.

PHYSICAL REQUIREMENTS:

• Able to speak clearly and distinctly with staff, physicians, patients, and other hospital employees.
• Able to extensively utilize telephone, email, and written communication.
• Demonstrates adequate stamina to deal with stressful situations and to complete the necessary work schedule.
• Able to sit/stand/walk for extended periods of time throughout the work schedule with some lifting and bending.
• Must have adequate perception of sounds or adequate hearing with corrections.
• Demonstrates adequate vision, or correctable with glasses/contacts, for reading current literature and preparing written documents. Must be able to distinguish colors.
• Fine motor skills and hand/eye coordination to operate business office machines.