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Community First Medical Center
Overview
The Clinical Documentation Specialist ensures the quality and completeness of patient medical records through concurrent review and collaboration with physicians and care teams. They facilitate documentation improvements to accurately reflect patient severity, risk of mortality, and intensity of service.
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Compensation
$70,000 - $85,000 / YEAR
Posted
2 days ago
Ascension
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.
$79,512 - $110,835 / YEAR
UVA Health
The Clinical Documentation Specialist evaluates physician documentation to ensure accurate representation of patient severity and coding specificity. They also provide guidance to medical and nursing staff on documentation best practices to improve hospital outcomes.
$85,000 / YEAR
6 days ago
The Clinical Documentation Specialist evaluates inpatient medical records to ensure accurate documentation of severity of illness and procedure coding. They also provide guidance to medical and nursing staff on documentation best practices to improve hospital outcomes.
$35 / HOUR
The Clinical Documentation Specialist evaluates inpatient medical records to ensure accurate documentation of severity of illness and diagnoses. They also provide guidance to medical and nursing staff on documentation best practices to improve coding accuracy and hospital outcomes.
The Orthopaedic Institute
The Medical Scribe assists physicians by accurately documenting medical visits, procedures, and patient information in real-time. They also manage clerical tasks, coordinate referrals, and ensure the integrity and confidentiality of medical records.
Salary not listed
8 days ago
Mercy Cedar Rapids
The Clinical Documentation Specialist reviews medical records to ensure accurate reflection of patient conditions and services provided. They collaborate with physicians and the coding team to resolve documentation issues and manage denials related to medical necessity.
University of Virginia
The Clinical Documentation Specialist evaluates physician documentation to ensure accurate representation of patient severity and coding specificity. They also provide guidance to medical staff on documentation best practices to improve hospital outcomes.
19 days ago
The Clinical Documentation Specialist evaluates inpatient medical records to ensure accurate severity of illness and coding specificity. They also provide guidance to clinical staff on documentation best practices to improve hospital and physician outcome reporting.
American Addiction Centers
Facilitate modifications of clinical documentation through interaction with physicians to ensure accurate capture of clinical severity and risk of mortality. Perform chart reviews and provide ongoing education to the healthcare team regarding coding and reimbursement issues.
$38 - $57 / HOUR
25 days ago
EvergreenHealth
The Clinical Documentation Specialist RN reviews inpatient medical records to ensure documentation accurately reflects patient severity and risk of mortality. They collaborate with providers and coding staff to facilitate corrections and ensure accurate reimbursement and outcome reporting.
28 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
Rochester Regional Health
The Clinical Documentation Specialist reviews medical records for completeness and accuracy regarding severity of illness, risk of mortality, complexity of care, and quality, while formulating and requesting documentation clarifications from physicians. This role also involves educating the patient care team regarding the CDS process and resolving documentation discrepancies with HIM staff.
$78,000 - $95,000 / YEAR
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
Day Kimball Healthcare
The CDI Specialist ensures accurate physician documentation to support severity of illness and risk of mortality in patient medical records. This involves reviewing records, collaborating with healthcare providers, and partnering with coding professionals to determine final DRG assignments.
$80,000 / YEAR
Ann & Robert H. Lurie Children's Hospital of Chicago
The primary responsibility involves the timely and accurate coding and abstracting of Inpatient visits using ICD-10 code sets, ensuring compliance with established guidelines. This role also requires validating DRG assignments, reviewing clinical documentation, and communicating documentation issues to specialists to ensure accurate reporting and reimbursement.
$32 - $52 / HOUR
Mission Regional Medical Center
The CDS Trainee conducts concurrent and retrospective reviews of inpatient medical records to ensure documentation reflects quality-of-care and reimbursement compliance. They collaborate with medical staff to facilitate accurate clinical documentation and evaluate admission criteria.
Beth Israel Lahey Health
The Clinical Documentation Improvement (CDI) Specialist Registered Nurse assists in identifying diagnoses, conditions, and procedures representative of the patient's hospital stay, including Severity of Illness and Risk of Morality. This role involves initiating concurrent queries to providers to improve data accuracy and quality, and educating staff on documentation best practices.
$76,960 - $103,578 / YEAR
Tenet Healthcare Corporation
The Clinical Documentation Specialist performs concurrent and retrospective reviews of inpatient medical records to ensure accurate documentation of patient severity and risk. They play a key role in reporting quality outcomes and ensuring compliant reimbursement for acute care services.
Self Regional Healthcare
The specialist will perform utilization review and clinical documentation tasks to ensure compliance with reimbursement requirements. They will also interpret clinical policies and procedures while providing care coordination across various patient age groups.
2 months ago
