BUSINESS & MANAGEMENT CONSULTANT
About The Position
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
Requirements
- License to practice as a Registered Nurse preferred (any state)
- Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)
- 1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience
- CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required
Responsibilities
- Improving the overall quality and completeness of clinical documentation
- Facilitates necessary documentation in the medical record
- Educates physicians regarding clinical documentation needs
- Applies knowledge of medical terminology and procedures to evaluate clinical documents
- Acute Care (inpatient) medical record monitoring
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
