Clinical Documentation Specialist at Magicforce Raleigh, NC

Neier Inc.; Raleigh (NC); On-site; USD 60,000 - 80,000; Full time

Job summary

Neier Inc. is seeking a Clinical Documentation Specialist in Raleigh, North Carolina. The role demands strong qualifications in clinical documentation improvement and coding, focusing on inpatient records. Candidates must have relevant certifications and at least one year of acute care experience.

The selected individual will work closely with physicians to enhance documentation quality, ensuring proper reimbursement. Responsibilities also include educating medical staff on documentation guidelines and monitoring clinical records.

Qualifications

• License to practice as a Registered Nurse preferred.
• 1-year Acute Care Concurrent Clinical Documentation Specialist experience required.
• Experience with medical record review and coding necessary.

Responsibilities

• Responsible for improving overall quality of clinical documentation.
• Facilitates necessary documentation interactions with physicians and staff.
• Educates physicians on documentation needs and coding opportunities.

Skills

Clinical documentation improvement

Inpatient coding

Communication skills

Education

RHIA, RHIT, or CCS credentials

CCDS or CDIP credential

Job description

Qualifications

• Must have at least one of the following:
  • License to practice as a Registered Nurse (preferred, any state)
  • Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)
• Must have all of the following:
  • 1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience
  • CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required

Additional notes: Candidate must have at least 1 year of experience with concurrent inpatient facility coding/clinical documentation improvement experience. We are looking for someone who has had experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation obtaining missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided.

Responsibilities

• Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.
• Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients.
• Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an ongoing basis.
• Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities.
• Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses, obtaining missing information via a query when necessary.