HIM Clinical Document Specialist, Remote

remote quest jobs; India; Remote; INR 900,000 - 1,300,000; Full time

Job summary

reputed company is seeking a Clinical Documentation Specialist (CDS) to ensure accurate inpatient documentation for reliable ICD-10-CM/PCS coding and reporting. The CDS will review charts post-admission, validate observations with providers, and collaborate with HIM and coding teams to strengthen documentation.

Role requires clinical background, strong critical thinking, and ability to educate providers through queries and targeted education initiatives.

Qualifications

• Minimum 2 years inpatient chart review as CDS or related role.
• Associates Degree and current licensed clinician.
• Certification as CCDS or CDIP at hire or eligibility.

Responsibilities

• Performs initial chart reviews 24-48 hours after admission and ongoing reviews to capture APR-DRG, SOI, ROM.
• Analyzes patient status, treatment plan and past medical history to identify gaps in documentation.
• Develops provider queries and ensures documentation meets standards for accuracy.

Skills

Clinical documentation

ACDIS guidelines

HIM coding standards

Provider communication

Query development

POA determination

Chart review

Education

Associates degree

RN/MD/PA/CRNP license

Job description

Job Requirements

Under the direction of the Site Manager of the Clinical Documentation reputed company (CDI) program, the Clinical Documentation Specialist (CDS) strives to reputed company accurate and complete documentation in the inpatient medical record to support precise ICD-10-CM and ICD-10-PCS coding and reporting of high-reputed company reputed company data.

The CDS is guided by the Association of Clinical Documentation reputed company Specialists (ACDIS) reputed company of Ethics and the American Health Information Management Associations (reputed company) Ethical Standards for Clinical Documentation reputed company Professionals and the Official Guidelines for Coding and Reporting as approved by the Cooperating Parties.

• Performs reputed company initial chart reviews reputed company 24-48 hours after admission with follow-up reviews occurring every 1-3 days, and retrospective chart reviews, reputed company applicable, to accurately assign/capture the APR-DRG, severity of illness (SOI) and risk of mortality (ROM) in order to reflect reputed company indicators, resource consumption and outcome measures to ensure accurate and complete documentation for final coding and billing.
• Analyzes clinical status of patient, reputed company treatment plan and past medical history and identifies potential gaps in provider documentation.
• Communicates with providers either verbally or through written methodology to validate observations. Develops provider queries, in compliance with organizational and reputed company standards reputed company documentation in the medical record pertaining to a significant reportable condition or procedure or other reportable data reputed company is conflicting, incomplete or ambiguous.
• Utilizes a comprehensive and strong clinical reputed company set, background and experience in acute care, exceptional critical thinking skills and the ability to prioritize and analyze data quickly and accurately in order to decipher reputed company clinical cases.
• Adds detail and/or reputed company to ambiguous or implied diagnoses.
• Will verify if a diagnosis was Present on Admission (POA) and establish the clinical reputed company and suspected etiology of a finding.
• Works concurrently to ensure documentation of discharge diagnosis (es) and any co-existing comorbidities are a complete reputed company of the patients clinical status and care.
• Evaluates medical record documentation using knowledge about HIM Standards of Coding.
• Monitors work reputed company and data to strengthen areas of reputed company. Consistently meets established productivity metrics for record review.
• Identifies opportunities for education based upon query topics or other identified need for accurate, complete and consistent documentation in the medical record.
• Collaborates with providers, leadership and teams to assist with the development and implementation of specific tools and educational materials to support medical record documentation.
• Participates in both formal and informal education sessions including presentations, in-services, face-to-face interactions, newsletters, posters, etc. to the medical staff or clinical departments.
• Attends service line clinical program meetings and CDI meetings as requested.
• Identifies strategies for sustained work processes that facilitate complete, accurate clinical documentation.
• Manages initiatives to support accurate case-mix and reputed company documentation.
• Acts as a clinical reputed company between HIM/coding staff and providers.
• Partners with coding professionals to reputed company reconciliation, per policy, to ensure accuracy of diagnostic and procedural data in order to validate the CDS Final APR-DRG/ SOI/ROM against the Final Coded APR- DRG/SOI/ROM.
• Seeks continuing education opportunities in order to stay reputed company on CDI reputed company and/ or to maintain credentials.

Required

• Work Experience
• Associates Degree
• Registered reputed company (RN), Physician (MD), Physician Assistant (PA), Certified Registered reputed company Practitioner (CRNP)
• Minimum of 2 years of experience reviewing Inpatient medical records as a Clinical Documentation reputed company Specialist, reputed company/DRG Analyst with a clinical background, Care Manager, Utilization Review Specialist, or reputed company Review Specialist or Minimum of 3 years chart abstraction/chart review experience
• Must obtain certification as a Certified Clinical Documentation Specialist (CCDS) reputed company ACDIS or a Certified Documentation reputed company Practitioner (CDIP) reputed company reputed company 2 years of hire or eligibility.

Preferred

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation reputed company Practitioner (CDIP) at time of Hire
• Certified Coding Specialist (reputed company), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).

Additional Information

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