CDI & Medical Records Compliance Specialist

0090 Presbyterian System Services; United States; On-site; USD 66,000 - 112,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Disability insurance

Life insurance

Wellness program

Smoke-free campuses

Drug-free employer

Job summary

Presbyterian Healthcare Services in Albuquerque, NM is hiring a Clinical Documentation and Compliance Specialist to support accuracy of medical records and coding through collaboration with physicians and HIM staff.

The role requires experience with ICD-10/CPT/HCPCS and CCDS certification plans, with strong attention to detail and communication skills to ensure proper clinical severity is captured for hospital and physician billing.

Qualifications

• Associates degree in Nursing or Bachelor's with CDI experience.
• CCD S (Certified Clinical Documentation Specialist) within 3 years.
• Working knowledge of ICD-10, CPT, HCPCS, DRG and related procedures.
• Experience with database, spreadsheet and word processing.

Responsibilities

• Perform concurrent reviews of the medical record for inpatient admissions and document DRG-related findings.
• Collaborate with medical staff to improve chart documentation reflecting services provided.
• Assist physicians with documentation to support medical necessity for billing.
• Interpret clinical information and query as needed for supporting progress notes and histories.

Education

Associates degree in Nursing

Bachelor's degree with CDI experience

Job description

Presbyterian Healthcare Services in Albuquerque, NM is hiring a Clinical Documentation and Compliance Specialist to support accuracy of medical records and coding through collaboration with physicians and HIM staff.

The role requires experience with ICD-10/CPT/HCPCS and CCDS certification plans, with strong attention to detail and communication skills to ensure proper clinical severity is captured for hospital and physician billing.