Clinical Documentation & Compliance Expert

Presbyterian Healthcare Services; Albuquerque (NM); Sur place; USD 66 000 - 112 000; Plein temps

Résumé du poste

Presbyterian Healthcare Services in Albuquerque, NM seeks a Clinical Documentation and Compliance Specialist to review and ensure accuracy of medical records. You will work with physicians to obtain precise diagnoses and procedures, supporting medically necessary hospital and physician billing.

The role requires strong regulatory knowledge, communication skills, and the ability to prioritize workload in a fast-paced hospital setting. Full-time, weekday schedule.

Qualifications

• Associates degree in Nursing with 5 years clinical experience, or a Bachelors with 2 years CDI experience.
• CCDS certification within 3 years of employment.
• Working knowledge of ICD-10, CPT, HCPCS, DRG and related procedures.
• Up-to-date clinical knowledge including pathology and pharmacology impacts on care.
• Experience with databases, spreadsheets and word processing.
• Detail-oriented with ability to maintain accurate, organized records.

Responsabilités

• Perform concurrent reviews of inpatient records to assign DRG and identify comorbid conditions.
• Collaborate with Medical and Nursing staff to improve chart documentation for accuracy.
• Assist physicians with documentation to support medical necessity for billing.
• Interpret clinical information and query for supporting documentation in notes and consults.
• Solicit clarification of existing documentation to support severity of illness.
• Serve as expert resource for the HIM Coding team on documentation requirements.
• Coordinate with the HIM Coding team on coding guideline requirements.
• Maintain up-to-date knowledge of ICD-10, CPT, HCPCS, CMS updates and regulatory changes.

Connaissances

Medical terminology knowledge

ICD-10 knowledge

CPT knowledge

Spreadsheets & databases

Documentation detail

Formation

Associates degree in Nursing or Bachelors with CDI experience

Outils

Query tools

Description du poste

Presbyterian Healthcare Services in Albuquerque, NM seeks a Clinical Documentation and Compliance Specialist to review and ensure accuracy of medical records. You will work with physicians to obtain precise diagnoses and procedures, supporting medically necessary hospital and physician billing.

The role requires strong regulatory knowledge, communication skills, and the ability to prioritize workload in a fast-paced hospital setting. Full-time, weekday schedule.