Inpatient/CDI Specialist

Major Hospital; Shelbyville (IN); On-site; USD 65,000 - 90,000; Full time

Job summary

Major Hospital is seeking a Clinical Documentation Specialist to review and analyze medical records, identifying relevant diagnoses and procedures for distinct patient encounters. The role requires staying current with federal and state regulations impacting prospective payment and clinical treatment changes.

Additionally, the position includes Utilization Management duties, evaluating medical necessity, appropriateness, and efficiency of services, and performing queries when physician

Qualifications

• Strong computer skills required.
• Excellent written and verbal communication abilities.
• 3+ years of medical coding experience.
• Experience with 3M CDIS software preferred.

Responsibilities

• Review and analyze medical records to identify relevant diagnoses and procedures for patient encounters.
• Perform Utilization Management duties: evaluate medical necessity, appropriateness, and efficiency of care.
• Submit queries when physician documentation is vague or missing.

Skills

Computer skills

Communication skills

Medical coding experience

3M CDIS software

Education

Bachelor's degree or higher

Tools

3M CDIS software

Job description

The Clinical Documentation Specialist reviews and analyzes medical records to identify relevant diagnoses and procedures for distinct patient encounters. This position is challenged to be aware of the continual changes in Federal and State regulations for prospective payment, keep informed of changes in clinical treatment modes and new procedures, and to perform queries when Physician documentation is vague or missing. The Clinical Documentation Specialist also performs Utilization Management duties including: evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedure and facilities under the provisions of the applicable health benefits plan.

MINIMUM QUALIFICATIONS

Professional & Technical Skills

Strong computer skills. Effective communication skills, both written and verbal; three years or greater of medical coding experience; experience with 3M CDIS software preferred.

Education

BachelorsDegree or above, preferred

License(s) or Certification(s)

Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or Certified Inpatient Coder (CIC) certification. ICD10 prepared. Clinical Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification preferred. LPN or RRT or RHIA/RHIT preferred.

Other Skills or Requirements

Ability to work independently. Exceptional customer service and critical thinking skills.

Skilled to Care for Certain Age-Related Patient Groups (incumbents will be skilled in the care of the following patient groups)

• _____ Does not apply _____ Adolescence (13-17 years)
• __X__All age groups
• _____ Infants (0-1 year)
• _____ Geriatric (65+ years)
• _____ Pediatric/Early Childhood (1-12 years)
• _____ Adult (18-64 years)