Clinical Documentation Specialist

Ascension; United States; Remote; USD 65,000 - 90,000; Full time

Job summary

Ascension is seeking a Remote Clinical Documentation Specialist to perform admission reviews, assign working DRGs, and ensure accurate documentation in the CDI system. You will collaborates with physicians to obtain detailed medical record information and resolve queries before discharge.

The role requires active engagement with clinicians to reflect severity of illness and services provided, with strong record-keeping of CDI activities and outcomes.

Qualifications

• Credentials must be obtained within 6 months of hire date or job transfer date (CCS).
• Credentials must be obtained within 6 months of hire date or job transfer date (CPC).
• Clinical Documentation Prof. credentialed from any recognized body before hire date.
• Licensed Compact State RN credentialed before hire date.
• Reg Health Info Admin credentialed before hire date.
• Reg Health Info Tech credentialed before hire date.

Responsibilities

• Completes admission reviews and assigns a working DRG and enters information into the CDI database.
• Initiates and maintains extensive interactions with physicians and mid-level providers to address documentation needs.
• Collaborates to ensure severity of illness and level of services reflected accurately and resolves physician queries prior to discharge.
• Maintains accurate records of review activities and CDI outcomes.

Education

High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience

Job description

Description

• Location: Remote


• Facility: Saint Thomas Health


• Department: Clinical Documentation


• Schedule: Full-time | Days

Responsibilities

• Completes admission reviews and assigns a working Diagnosis Related Group. Ensures the working DRG and other information are entered in the Clinical Documentation Improvement database.


• Initiates and maintains extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.


• Collaborates with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.


• Maintains accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.

Qualifications

Licensure / Certification / Registration

• Required Credential(s):
  
  
  
  • One or more of the following:
    
    
    
    • Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained within 6 Months (180 days) of hire date or job transfer date.
    
    
    • Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained within 6 Months (180 days) of hire date or job transfer date.
    
    
    • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
    
    
    • Licensed Compact State Registered Nurse credentialed from the Tennessee Board of Nursing obtained prior to hire date or job transfer date.
    
    
    • Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    
    
    • Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    
    
    
    
  
  
  
  

Education

• High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.