Job Description
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Responsible for facilitating the improvement in the overall quality and completeness of provider based clinical documentation in the patient record, assisting providers to ensure that documentation in the patient record accurately reflects the severity of illness of the patient as well as the level of services rendered. The Clinical Documentation Specialist assesses clinical documentation through extensive review of the patient record, interaction with providers and Clinical Revenue Cycle coding staff to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.
Accountabilities All duties listed below are essential unless noted otherwise - Performs patient record reviews, identifying opportunities for documentation improvement.
- Demonstrates knowledge of Official Coding Guidelines and utilize CDI program software and tools to accurately input data. Demonstrates knowledge of MS-DRG and APR-DRG methodologies.
- Develops and delivers clinical documentation improvement education to providers.
- Utilize all electronic resources available, including Epic, 3M Coding and Reimbursement System, reference tools and accurately inputs data for daily workflow production.
- Communicates with providers, coders and other members of the patient’s care team as needed to achieve comprehensive patient record documentation.
- Establish and maintain effective and professional working relationships with all internal and external customers.
- Formulates, monitors, and responds to all compliant documentation clarification requests to query the provider for resolution of incomplete documentation, which will be issued through 3M 360.
- Adheres to ProMedica’s System and Clinical Revenue Cycle department policies and procedures related to this position.
- Attend/complete all assigned training to develop relevant knowledge and skills related to their job for continued educational growth and experience.
- Attend and participate in required meetings.
- Accurately abstracts and verifies the required data into all applicable health information systems per established standards.
- Consistently meets the quality and productivity standards for clinical documentation specialists in accordance with the current productivity standards and policy.
- Demonstrates self-direction and ability to work independently.
- Performs other related duties as assigned.
- Follows the System confidentiality and security policies at all times. Education: Associate degree in Health Information Management or related field.
Skills: Strong interpersonal and communication skills required. Knowledge of inpatient coding and Clinical Documentation Improvement Effective verbal and written communication skills. Demonstrates knowledge of computer skills and applications, including Epic, 3M 360, and the Microsoft Office suite of applications.
Years of Experience: 1-2 years of inpatient coding experience.
License: RN with active state licensure OR
Certification: RHIA/RHIT, CCS, CDIP, CCDS
Preferred Qualifications Education: Bachelor of Nursing or bachelor’s degree in Health Information Management or related field.
Skills: Ability to use various computer systems and applications. Knowledge of entire revenue cycle process.
Years of Experience: Experience with acute care inpatient coding or clinical documentation improvement.
Certification: RN, RHIA/ RHIT, CCS, CDIP, CCDS
The above list of accountabilities is intended to describe the general nature and level of work performed by the incumbent; it should not be considered exhaustive.
ProMedica is a mission-based, not-for-profit integrated healthcare organizational headquartered in Toledo, Ohio. For more information, please visit
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org
Equal Opportunity Employer/Drug-Free Workplace
Requisition ID: 93858
Job Tags
Full time, Remote job,