Clinical Documentation Improvement Expert

College of Pastoral Supervision and Psychotherapy; Pinehurst (NC); On-site; USD 70,000 - 90,000; Full time

Job summary

College of Pastoral Supervision and Psychotherapy seeks a Clinical Documentation Improvement Specialist to perform concurrent and retrospective reviews, educate providers, and improve documentation in health records to reflect patient conditions accurately.

The role focuses on MS-DRG assignment, case mix index, severity of illness, risk of mortality, profiling, and reimbursement rules, with ongoing collaboration across clinical staff and coding teams.

Qualifications

• BSN preferred.
• NC Nursing License required.
• Five years clinical experience required.
• Coding skills with ICD-10 training.
• Working knowledge of the AHA Coding Clinic preferred.
• Previous experience with clinical documentation preferred.
• CDS certification preferred.

Responsibilities

• Conducts initial and extended-stay concurrent review and documents findings.
• Identify co-morbidities and complications and document appropriately.
• Queries the medical staff to obtain accurate and complete documentation.
• Identify quality, severity of illness, risk of mortality, and reimbursement issues.
• Communicate documentation issues clearly to clinical care providers.
• Act as the liaison between clinical care providers and coding professionals.
• Provide ongoing education to physicians on documentation, coding changes, and compliance.
• Monitor changes in law, regulations, rules, and code assignment impacting documentation.

Skills

Coding skills (ICD-10)

AHA Coding Clinic knowledge

Clinical documentation

Education

BSN

NC Nursing License

Job description

College of Pastoral Supervision and Psychotherapy seeks a Clinical Documentation Improvement Specialist to perform concurrent and retrospective reviews, educate providers, and improve documentation in health records to reflect patient conditions accurately.

The role focuses on MS-DRG assignment, case mix index, severity of illness, risk of mortality, profiling, and reimbursement rules, with ongoing collaboration across clinical staff and coding teams.