CDI Specialist: Elevate Documentation & Coding Quality

Jobtailor; City of Oneida (NY); On-site; USD 80,000 - 120,000; Full time

Job summary

Jobtailor in the United States is seeking a Clinical Documentation Improvement Specialist to enhance documentation accuracy and coding precision. You will partner with physicians and nurses to obtain clarifications, train staff on best practices, and drive ongoing process improvements across clinical documentation workflows.

The role requires a background in nursing or health information management, experience with Meditech EHR, and familiarity with coding guidelines and healthcare regulations.

Qualifications

• Bachelor's degree in nursing, health information management, or relevant field.
• Clinical experience in a hospital setting preferred.
• CCDS or CCS certification preferred.
• Proficiency with Meditech EHR system.
• Strong knowledge of coding guidelines and healthcare regulations.

Responsibilities

• Review patient medical records to identify opportunities for enhanced documentation accuracy.
• Collaborate with physicians, nurses, and other healthcare professionals to obtain clarification and additional information supporting precise coding.
• Educate and train clinical staff on documentation improvement and coding guidelines.
• Analyze coding and documentation trends to identify areas for process improvement and implement strategies to address deficiencies.
• Assist in developing and implementing policies and procedures related to clinical documentation improvement.
• Stay updated on changes in coding guidelines, regulations, and Meditech updates to ensure compliance and adherence to best practices.

Skills

Clinical Documentation Improvement

Coding Guidelines Knowledge

Healthcare Regulations Understanding

Documentation Accuracy Review

Process Improvement Analysis

Education

Bachelor's degree in nursing, health information management, or relevant field

Tools

Meditech EHR System

Job description

Jobtailor in the United States is seeking a Clinical Documentation Improvement Specialist to enhance documentation accuracy and coding precision. You will partner with physicians and nurses to obtain clarifications, train staff on best practices, and drive ongoing process improvements across clinical documentation workflows.

The role requires a background in nursing or health information management, experience with Meditech EHR, and familiarity with coding guidelines and healthcare regulations.