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UVA Health
Overview
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.
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Compensation
$85,000 / YEAR
Posted
6 days ago
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.
$35 / HOUR
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.
Salary not listed
8 days ago
Cheyenne Regional Medical Center
The specialist improves the quality and completeness of provider documentation through daily interaction with clinical and coding staff. They review medical records to ensure accurate reflection of patient severity and acuity while educating the care team on regulatory guidelines.
11 days ago
UMass Memorial Health
Collaborates with physicians and staff to ensure patient records accurately reflect the severity of illness and risk of mortality. Analyzes clinical status and treatment plans to identify and resolve gaps in medical documentation for coding and reimbursement purposes.
$87,277 - $157,082 / YEAR
17 days ago
University of Virginia
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.
19 days ago
MaineGeneral Health System
Assigns diagnosis, procedure, and DRG codes to ensure accurate reimbursement and quality documentation. Collaborates with CDI staff and healthcare providers to optimize severity of illness documentation and resolve coding discrepancies.
21 days ago
Unity Health
The Clinical Documentation Improvement Specialist facilitates modifications to medical records through concurrent interaction with physicians to ensure accurate clinical severity and billing levels. They evaluate documentation, lab results, and treatment plans to support the level of service rendered.
1 month ago
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.
Regal Medical Group
The Case Manager assesses, plans, intervenes, monitors, and documents patient care during acute episodes, focusing on facilitating timely transfers for Medi-Cal members into capitated hospitals. They manage hospitalization to ensure the right level of care and coordinate safe discharges with necessary post-acute resources, including a 24-hour follow-up call.
$45 - $50 / HOUR
2 months ago
Centra Health
The Inpatient Coding Specialist reviews medical records to assign accurate ICD-10-CM and ICD-10-PCS codes for optimal reimbursement. They also collaborate with clinical documentation teams and formulate provider queries to ensure coding accuracy.
Prisma Health
The specialist conducts concurrent and retrospective medical record reviews to validate diagnoses, ensure documentation clarity, completeness, and accuracy, and reflect the patient's severity of illness. This involves employing the query process with providers and completing reconciliation to ensure accurate coding reflective of patient status.
University of Mississippi Medical Center
The specialist supports and reviews inpatient medical records to improve documentation quality, completeness, clinical severity, and accuracy for specific departments, obtaining appropriate documentation through extensive interaction with physicians and the healthcare team. Responsibilities include reviewing charts within 24-48 hours of admission, assigning working DRGs, identifying comorbidities, and communicating documentation improvement opportunities clearly to providers.
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.
3 months ago
Hollywood Presbyterian
The case manager's primary focus is to integrate, coordinate, and advocate for patients requiring extensive services to ensure desirable outcomes, efficient resource utilization, and appropriate lengths of stay. This involves assessing patients for acute care admission, arranging post-hospital care needs, coordinating transfers, and consulting with physicians on discharge plans.
$56 - $89 / HOUR
The case manager's primary focus is to integrate, coordinate, and advocate for patients requiring extensive services to ensure desirable patient outcomes, efficient resource utilization, and appropriate lengths of stay. Responsibilities include assessing patients for acute care setting appropriateness, arranging post-hospital care needs, coordinating transfers, and consulting with physicians regarding discharge plans.
UHS
The Utilization Review Specialist is tasked with evaluating medical records to determine the severity of a patient's illness and the appropriate level of care required. This role also involves serving as a liaison with insurance companies and overseeing UR activities across departments to ensure proper reimbursement for services.
UF Health
The specialist is responsible for improving inpatient clinical documentation by concurrently reviewing medical records to ensure accuracy based on clinical evidence and ICD-10-CM coding guidelines. This involves identifying documentation enhancement opportunities and querying physicians for clarification to accurately reflect the patient’s severity of illness and risk of mortality.
The specialist is responsible for improving inpatient clinical documentation by concurrently reviewing medical records to ensure accuracy based on clinical evidence and ICD-10-CM coding guidelines. This involves identifying documentation enhancement opportunities and querying physicians to support more specific and accurate diagnoses.
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.
