Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected. Meets or exceeds defined performance standards for chart reviews and queries.
Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. Serves as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.
Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills.
Performs ongoing CDI Final Review/DRG Reconciliation and reports DRG mismatch disagreements for secondary review as defined.
Other related job tasks or responsibilities as assigned

Special Skills:
Knowledge of care delivery documentation systems and related medical record documents.
Detailed knowledge and understanding of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment.
Excellent written and verbal communication skills, critical thinking skills, and interpersonal skills to build effective relationships with physician, case management, nursing, coding, and hospital staff.
Computer skills and familiarity with basic office equipment required. Ability to work independently in a time oriented environment. Self
directed, motivated, and possess a positive attitude.
Minimum Requirements
Education: Graduate of an accredited school of nursing, AHIMA accredited school, United States, or international school of medicine
Experience: 2 to 5 years of CDS experience and 2 years recent acute care experience in a clinical or inpatient coding setting; or MBBS and USMLE in lieu of experience.
Certifications: One of the following is required: RN, LVN, LPN, RHIA, RHIT, CCS, CIC, MD, DO, PA, or NP.

Medical, dental, vision, and life insurance
401(k) retirement savings plan with employer match
Generous paid time off
Career development and continuing education opportunities
Health savings accounts, healthcare & dependent flexible spending accounts
Employee Assistance program, Employee discount program
Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Clinical Documentation Specialist II

Key skills