Clinical Documentation Specialist - CMG

CaroMont Health; Gastonia (NC); On-site; USD 70,000 - 90,000; Full time

Job summary

CaroMont Health in Gastonia, NC seeks a Clinical Documentation Improvement (CDI) Coordinator to coordinate data and documentation compliance, collaborating with physicians, advanced practice providers, and HIM coders to identify documentation improvement opportunities.

You will review medical records across concurrent, prospective, and retrospective evaluations, query staff as needed to ensure documentation supports severity of illness, resource use, and risk of mortality, and participate in

Job description

Job Summary

Responsible for the coordination of data and clinical documentation compliance to improve clinical documentation integrity. Collaborates directly with Physicians, Advanced Practice providers and HIM Coders where documentation improvement opportunities exist. Reviews clinical documentation in the medical record, through concurrent, prospective and retrospective evaluation, and queries the medical staff and other care givers as necessary to obtain accurate and complete documentation which appropriately supports the severity of patient illness, resource consumption and risk of mortality and readmissions. Ensures the accuracy and integrity of clinical documentation used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis as needed. Participates in ongoing committees as needed.