The Clinical Documentation Specialist reviews medical records while a patient is in the hospital, and identifies documentation needs in the medical record. They communicate, either verbally or in writing, with physicians to clarify documentation in the medical record.
Essential Duties and Responsibilities:
- Provides CDI instruction to classes of nurses, CDI coding professionals, and other ancillary personnel.
- Coordinates types and numbers of reviews each day with the needs presented
- Reviews medical records concurrently (while patient is in the hospital), or retrospectively per client request
- Reports to the designated manager in the hospital
- Serves as an employee with all the requirements set forth by Company structure
- Meets clients’ minimum agreed review rates (generally no more than 25 new admissions and reviews combined per day)
- Facilitates communication among coders, physicians, and utilization nurses to identify documentation opportunities
- Teaches MDC methodology to the client, identifying CDI opportunities for documentation clarification
- Leads CDI-applicable presentations to Ancillary department (Physical Therapy, Nursing, Dietary, etc.)
- Coordinates classroom presentations
- Performs other duties as assigned/necessary
- Must hold at least one of the following certifications: CCS, RHIT, RHIA, RN, or MD certification
- Minimum of 12 months of CDIS application experience within the last three years of application
- Must possess and utilize knowledge of the CDI review process, CDI strategies, compliant CDI query technique, and non-leading provider communication.
- Must be trained in ICD-10-CM/PCS and provide evidence of training.
- Must be willing and able to travel, or work remotely, based on assignment
- Must be willing and able to travel on-site as required by the client, based on assignment needs
- (i.e. training, etc.) perform on-site three weeks in a row (any more will be cleared through MHIS CDIS)
- Ability to effectively elicit/provide information to and from appropriate individuals (including, but not limited to, supervisors, co-workers, clients) via strong communication skills; proficiency in the English language may be required
- Computer proficiency required
- Must be at least 18 years of age
At Maxim Healthcare Services, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:
- Competitive pay & weekly paychecks
- Health, dental, vision, and life insurance
- 401(k) savings plan
- Awards and recognition programs
*Benefit eligibility is dependent on employment status.
Maxim Healthcare Services is a leading provider of home healthcare, medical-related staffing, travel nursing, and population health and wellness services across the United States. As an established community partner, we have been making a difference in the lives of our employees, caregivers, and patients for more than 30 years. Our commitment to customer service, improving patient care, and staffing experienced healthcare professionals has paved the way for many rewarding career opportunities in the healthcare industry.
Maxim Healthcare Services, Inc. is an Affirmative Action/Equal Opportunity Employer
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