Clinical Documentation Improvement Specialist

Oneida Health; City of Oneida (NY); On-site; USD 65,000 - 85,000; Full time

Job summary

Oneida Health in the City of Oneida, NY is seeking a Clinical Documentation Improvement Specialist to enhance the accuracy of clinical documentation within the electronic health record system. The role involves conducting thorough reviews of patient records and collaborating with healthcare providers to ensure accurate coding.

Applicants should have a Bachelor's degree in a relevant field and clinical experience in a healthcare environment. A focus on communication and collaboration is essential, along with proficiency in Meditech EHR system.

Qualifications

• Clinical experience in a healthcare setting, preferably in a hospital environment.
• Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Coding Specialist (CCS) certification preferred.

Responsibilities

• Conduct thorough reviews of patient medical records.
• Collaborate with physicians and nurses for documentation accuracy.
• Educate clinical staff on coding guidelines and best practices.
• Analyze documentation trends for process improvement.

Skills

Attention to detail

Excellent communication and interpersonal skills

Ability to collaborate effectively with multidisciplinary teams

Education

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

Tools

Meditech EHR system

Job description

Job Title: Clinical Documentation Improvement Specialist

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

Education

• 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.