Clinical Documentation Specialist

Clarity Partners LLC

$110K — $130K *
Hospitals & Medical Centers
Less than 5 years of experience
Job Overview by Ladders

Qualifications

  • License to practice as a Registered Nurse preferred or hold relevant credentials (RHIA, RHIT, CCS)
  • 1 year of acute care (inpatient) clinical documentation specialist experience required
  • CCDS or CDIP credential is mandatory
  • Experience in concurrent inpatient facility coding and clinical documentation improvement
  • Proficient in acute care medical record reviews, particularly for accuracy in diagnoses and treatments

Responsibilities

  • Facilitate documentation in medical records through collaboration with physicians and coding staff
  • Educate physicians on clinical documentation needs and coding opportunities
  • Apply medical terminology knowledge to identify documentation and reimbursement opportunities
  • Monitor acute care medical records to validate documentation accuracy and resolve discrepancies via queries

Benefits

  • Remote working environment
  • Continuous education opportunities through ongoing training for physicians
  • Engagement with a respected healthcare entity (Cook County Health)
  • Opportunity to impact reimbursement and quality of care directly through documentation improvement
Full Job Description
Clarity Partners is seeking a Clinical Documentation Specialist to support an engagement with Cook County Health (CCH). In this role, you will work under limited direction and according to clinical documentation guidelines and established policies and procedures to improve the overall quality and completeness of clinical documentation in the legal medical record. You will facilitate necessary documentation through extensive interaction with physicians, HIM, and coding staff to ensure the most appropriate reimbursement and highest level of severity of illness/risk of mortality (SOI/ROM) for the level of service rendered to all patients. This position plays a critical role in ensuring the accuracy of clinical documentation and supports appropriate coding and billing for services provided. This position will report in a remote setting.

Responsibilities
  • Facilitate necessary documentation in the medical record through extensive interaction with physicians, HIM, and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients.
  • Educate physicians regarding clinical documentation needs, changes to clinical documentation guidelines, and coding and reimbursement opportunities on an ongoing basis.
  • Apply knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities.
  • Perform 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.


Requirements

Requirements
  • At least one of the following: license to practice as a Registered Nurse preferred (any state); or credentialed as an RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), or CCS (Certified Coding Specialist).
  • 1 year of Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience required.
  • CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required.
  • Experience with concurrent inpatient facility coding/clinical documentation improvement required.
  • Experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation, obtaining missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided.

Clarity is committed to fair and equitable compensation practices. For the Clinical Documentation Specialist, the base salary pay range is $110,000 - $130,000. The range represents a good faith estimate that Clarity reasonably expects to pay for this job at the time of posting. Compensation will depend upon an individual's skills, experience, qualifications, location, and other relevant factors. The salary pay range is subject to change and may be modified at any time.

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