Clinical Documentation Improvement Specialist

Oneida-Healthcare; City of Oneida (NY); Vor Ort; USD 30.307 - 37.195; Vollzeit

Zusammenfassung

Oneida-Healthcare is seeking a Clinical Documentation Improvement Specialist who plays a pivotal role in enhancing clinical documentation accuracy within the EHR system, specifically utilizing Meditech.

The position requires a Bachelor's degree in nursing or a relevant field, along with clinical experience and preferred certifications. Successful candidates will work with healthcare professionals to ensure compliance and improve documentation quality.

Qualifikationen

• Deep understanding of clinical documentation and coding guidelines.
• Clinical experience in a healthcare setting, preferably in a hospital.
• Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Coding Specialist (CCS) preferred.

Aufgaben

• Conduct thorough reviews of patient medical records for documentation accuracy.
• Collaborate with healthcare professionals to ensure precise coding.
• Educate clinical staff on best practices for documentation improvement.

Kenntnisse

Attention to detail

Excellent communication

Interpersonal skills

Collaboration

Ausbildung

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

Tools

Meditech EHR system

Jobbeschreibung

Job Details

Job Location: Corporate - Oneida, NY 13421

Position Type: Full Time

Education Level: 2 Year Degree

Salary Range: $22.00 - $27.00 Hourly

Travel Percentage: None

Job Shift: Days Flex

Job Category: Accounting/Finance/Billing

Job Title: Clinical Documentation Improvement Specialist

Job Summary

As a Clinical Documentation Improvement Specialist, you play a pivotal role in elevating the accuracy and completeness of clinical documentation within the electronic health record (EHR) system, specifically utilizing the Meditech platform. Your primary responsibilities include conducting comprehensive reviews of patient medical records, collaborating with healthcare providers to ensure accurate coding, and implementing strategies for documentation improvement. Through education and training initiatives, you contribute to enhancing the overall quality of documentation, complying with coding guidelines, and fostering effective communication among multidisciplinary teams.

Key Responsibilities

• Conduct thorough reviews of 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 best practices for 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.

Requirements

This role requires attention to detail, a deep understanding of clinical documentation, and the ability to foster collaboration among healthcare professionals. If you are passionate about enhancing the quality of healthcare documentation and ensuring compliance, we invite you to apply for this impactful position.

Physical Requirements

• Ability to navigate and review electronic health records.
• Regular use of computer and office equipment.

Qualifications

• Bachelor's degree in nursing, health information management, or relevant field; prior experience will be considered.

Experience

• Clinical experience in a healthcare setting, preferably in a hospital environment.

Certifications

• Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Coding Specialist (CCS) certification preferred.

Technical Skills

• Proficiency in working with Meditech EHR system.
• Strong knowledge of coding guidelines, healthcare regulations, and clinical documentation requirements.

Soft Skills

• Excellent communication and interpersonal skills.
• Ability to collaborate effectively with multidisciplinary teams.