Job Description

POSITION SUMMARY:

Under the general direction of the Director of Revenue Integrity/Coding, the Clinical Documentation Improvement Specialist is responsible for the performance of clinical documentation improvement functions. This position serves as a resource for the other members of the coding team. This position will concurrently code and assign DRG and length of stay to patient accounts while patients are still in house. This position requires continuous review of medical records and clinical documentation. This position requires extensive communication with case management and physicians to support clinical severity of illness and risk of mortality of patients. Query process knowledge. Abstracts information from the medical record in compliance with state and other regulatory agencies. Knowledge of ICD-9 and reimbursement methodologies, documentation practices, and MS-DRG schemes highly preferred. Ability to utilize clinical knowledge in accordance with coding guidelines.

EDUCATION AND EXPERIENCE REQUIREMENTS:

  1. High school graduate or equivalent.
  2. Associate’s or Bachelor’s Degree in Health Information Technology/Management required/or Nursing(RN). RHIA, RHIT, CCDS, CDIP, and CCS certification required or eligible to sit for any of the above exams preferred.
  3. Proficiency in ICD-9 and CPT-4 hospital coding assignment preferred. Knowledge of medical terminology, anatomy and physiology, and pathophysiology preferred.
  4. Minimum of five (5) years previous inpatient and
  5. outpatient coding experience required in a hospital acute-care setting. Previous experience with clinical documentation improvement program preferred.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled

Application Instructions

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