Clinical Documentation & Coding Quality Specialist

China Reform Holdings Corporation; Concord (NH); On-site; USD 70,000 - 95,000; Full time

Job summary

Concord Hospital in Concord, NH seeks a Clinical Documentation Specialist (CDS) to improve the quality, completeness and compliance of clinical documentation. The CDS will review medical records, interact with physicians and staff, and educate the care team on documentation to support hospital resource use and patient acuity.

Required four years of education beyond high school, RN preferred, and CDIS/CCDS credential on hire or after eligibility.

Qualifications

• Four years of formal training or education beyond high school level (e.g., Bachelor’s Degree).
• RN preferred; CDIS/CCDS credential required upon hire or after eligibility requirements are met by ACDIS.
• Minimum of 4 years of related experience; coding knowledge is required.
• Knowledge of Microsoft software required; CDR2/Claro knowledge preferred.

Responsibilities

• Work product impacts the productivity and quality goals for clinical documentation improvement program.
• Demonstrates knowledge of MS-DRG's/APR-DRGs documentation requirements and guidelines.
• Obtains needed clarification of clinical documentation to ensure complete and accurate descriptions of services.
• Identifies trends in documentation opportunities and provides education to appropriate audiences to ensure compliance.
• Reports ongoing issues and improvement plans.
• Uses the software system to track and analyze outcomes of documentation improvement efforts.
• Assists in developing and maintaining clinical documentation improvement policies and procedures.
• Attends CDIP meetings and educational sessions and discusses trends from daily activities.
• Meets all departmental, professional and technical requirements.

Skills

Coding knowledge

Microsoft software

Education

Bachelor's Degree

Tools

CDIS/CCDS credential

Job description

Concord Hospital in Concord, NH seeks a Clinical Documentation Specialist (CDS) to improve the quality, completeness and compliance of clinical documentation. The CDS will review medical records, interact with physicians and staff, and educate the care team on documentation to support hospital resource use and patient acuity.

Required four years of education beyond high school, RN preferred, and CDIS/CCDS credential on hire or after eligibility.