Clinical Documentation Specialist II

Conifer Health Solutions, LLC.; United States; Remote; USD 85,000 - 110,000; Full time

Job summary

Conifer Health Solutions, LLC seeks a CDI Specialist to perform concurrent documentation review of inpatient records on site, clarifying diagnoses and procedures to improve coding accuracy. You will educate physicians and clinicians to capture complications and comorbidities, aligning with MSDRG guidelines while staying compliant with coding standards.

The role emphasizes ongoing DRG reconciliation, query management, and collaboration with physicians and hospital departments to drive

Qualifications

• Knowledge of care delivery documentation systems and related medical records.
• Detailed knowledge of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment.
• Excellent written and verbal communication skills and ability to build relationships with physicians, case management, nursing, coding, and hospital staff.
• Computer skills and familiarity with basic office equipment.
• Ability to work independently in a time-oriented environment.
• Self-directed, motivated, and positive attitude.

Responsibilities

• Initiates and performs concurrent documentation review of inpatient records to clarify conditions, diagnoses, and procedures, meeting performance standards.
• Educates physicians and clinicians to improve documentation and coding accuracy through queries, face-to-face communication, and educational programs.
• Remains current with coding guidelines to ensure accuracy and participates in educational programs and in-services.
• Supports the Coding Department by liaising with physicians to resolve open queries and advise on documentation quality.
• Identifies patterns of physician documentation issues and participates in improvement projects across departments.

Skills

Care documentation systems

MSDRG & OIG knowledge

Written & verbal communication

Computers & office tools

Independent time management

Self-motivated

Education

Nursing degree or AHIMA-certified program

Job description

Description

Position Summary - located on site NOT remote

Responsibilities

• Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected. Meets or exceeds defined performance standards for chart reviews and queries.
• Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. Serves as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.
• Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned base on documentation. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills.
• Performs ongoing CDI Final Review/DRG Reconciliation and reports DRG mismatch disagreements for secondary review as defined.
• Performs ongoing query reconciliation as defined, with regular monitoring of query outcomes for query performance opportunities.
• Supports the Coding Department through communicating with physicians regarding open queries; acts as liaison between coding and physicians.
• Identifies, assists, and participates in inter/intra-departmental special projects involving the accuracy of physician documentation.
• Collaborates with the Physician Advisor in identifying patterns of physician documentation issues, utilization/follow up of queries and education of physicians at the bedside and/or monthly meetings
• Maintains established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards. Maintains confidentiality and security levels to protect medical/legal patient care documentation.
• Participates in orientation, precepting, and mentoring of new team members.
• Other related job tasks or responsibilities as assigned

Qualifications

• Special Skills
  • Knowledge of care delivery documentation systems and related medical record documents.
  • Detailed knowledge andunderstanding of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment.
  • Excellent written and verbal communicationskills, critical thinking skills, and interpersonal skills to build effective relationships with physician, case management, nursing, coding, and hospitalstaff.
  • Computer skills and familiarity with basic office equipment required.
  • Ability to work independently in a time oriented environment.
  • Self-directed, motivated, and possess a positive attitude.
• Minimum Requirements
  • Education: Graduate of an accredited school of nursing, AHIMA accredited school, United States or international school of medicine
  • Experience: 2-5 years CDS experience
  • Licensure/Certifications: One of the following is required: RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP