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Ascension
Overview
Facilitate the quality and accuracy of medical record documentation by performing admission reviews and assigning working Diagnosis Related Groups. Collaborate with physicians and healthcare providers to ensure severity of illness and services are accurately reflected prior to patient discharge.
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Compensation
$79,512 - $110,835 / YEAR
Posted
2 days ago
Conifer Health Solutions
Review medical records to ensure accurate clinical documentation, MS-DRG assignment, and severity of illness representation. Collaborate with physicians and the care team to resolve documentation queries and provide education on coding guidelines.
Salary not listed
11 days ago
Omega Healthcare Solutions
The specialist is responsible for improving the quality and completeness of clinical documentation within electronic health records through collaboration with physicians and coding staff. They ensure documentation accuracy to facilitate compliant coding and meet regulatory standards for reporting outcomes.
29 days ago
Cooper University Hospital
Ensure the quality and completeness of medical record documentation across all payor groups and DRGs to support accurate reimbursement. Facilitate documentation modifications through concurrent interaction with physicians and nursing staff while educating the patient care team.
$40 - $64 / HOUR
1 month ago
Duke Careers
Improve the quality and completeness of medical records through concurrent interaction with physicians and clinical staff. Ensure accurate depiction of patient severity, risk of mortality, and conditions present on admission in compliance with regulations.
Emanate Health
The Clinical Documentation Integrity Specialist facilitates the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other healthcare team members. This role involves communicating with providers via discussion or compliant queries to address unclear or conflicting diagnoses and ensuring documentation accurately reflects the patient’s clinical conditions and level of service.
$69 / HOUR
2 months ago
Connecticut Children's
This role involves identifying opportunities for physician documentation improvement to ensure patient conditions and care are accurately reflected, and working closely with physicians and other providers to clarify documentation and resolve discrepancies. The specialist also collaborates continuously with the hospital Inpatient Coding team and stays current with coding guidelines and documentation standards to support the CDI program.
3 months ago
Northwell
The Clinical Documentation Specialist facilitates and obtains appropriate clinical documentation to support the severity of illness and complexity of care. They work with physicians to clarify documentation and ensure accuracy in medical records.
Sarasota Memorial Health Care System
The specialist facilitates the improvement of clinical documentation quality and completeness to support coding in the post-acute inpatient setting by reviewing medical records concurrently until discharge. Responsibilities include querying physicians for diagnosis specificity to ensure accurate reflection of patient acuity and resource utilization, and providing necessary documentation and coding education.
NOR Healthcare Systems
The CDI Specialist conducts concurrent and retrospective reviews of inpatient medical records to ensure documentation reflects medical necessity and quality of care. They work closely with medical staff to resolve documentation ambiguities and facilitate accurate coding and reimbursement.
$93,800 - $128,950 / YEAR
Kenaitze Indian Tribe
The technician processes electronic and paper release of information requests while ensuring strict HIPAA compliance and data privacy. They also assist in electronic health record reviews, statistical reporting, and preparation for regulatory audits.
The Clinical Documentation Specialist improves the quality and completeness of clinical documentation in the EHR by interacting extensively with physicians, nursing, and coding staff to facilitate necessary modifications. This role ensures documentation accuracy for measuring outcomes and coordinates with coding staff to resolve discrepancies while providing ongoing training and support.
Exceptional Healthcare Inc.
The specialist will review inpatient medical records concurrently and retrospectively to find documentation gaps and create compliant, non-leading physician queries to clarify clinical information. They will also educate providers on documentation best practices and monitor key quality and reimbursement metrics.
Access Healthcare Staffing & Recruitment
The Clinical Documentation Coordinator conducts concurrent reviews of inpatient medical records to ensure accurate, complete, and compliant documentation. They collaborate with physicians, coding, and quality teams to improve clinical documentation metrics and support appropriate reimbursement and risk adjustment.
$39 - $61 / HOUR
4 months ago
MOUNTAIN VIEW HOSPITAL LLC
The Clinical Documentation Specialist will assist providers in creating and maintaining patient medical records while coordinating and analyzing data for quality measures. They will also communicate with medical staff regarding patient care documentation.
5 months ago
