Clinical Documentation Specialist - Waukegan - Revolution Technologies

    Revolution Technologies
    Revolution Technologies Waukegan

    3 days ago

    Description

    Clinical Documentation Specialist Qualifications


    • **Must have at least one of the following:**

    1. License to practice as a Registered Nurse preferred (any state)
    2. Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)


    • **Must have all of the following:**

    1. 3+ years Acute Care (inpatient) and Concurrent Clinical Documentation Specialist experience
    2. CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required

    Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.


    • Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and and highest level of SOI/ROM is achieved for the level of service rendered to all patients


    • Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis


    • Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities


    • Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses – obtaining missing information via a query when necessary


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