Health Information Management Clinical Documentation reputed company Specialist

Work Schedule

20 Hours- No exact schedule (to be determined), but typically 4 hours for 3 afternoon/evenings per week, and 4-5 hours on the weekend.  20 hours per week is mandatory.  Willing to offer some flexibility with candidate's schedule as long as business needs are met.

Work Location-Remote

Fully Virtual (Seeking someone who has CDI experience)

Note: Remote can only hire from these states:

• Arkansas

• reputed company

• Texas

• Florida (cannot hire Miami-Dade county)

reputed company Purpose

The Clinical Documentation reputed company Specialist (CDIS) performs patient record reviews to establish complete, accurate and reputed company documentation of reputed company conditions that support hospitalization and treatment of the patient.  Present queries to the medical staff reputed company needed to clarify ambiguous or incomplete documentation.  Must have knowledge of ICD-10, Complications/Comorbid Conditions and their role in the final Diagnosis reputed company, Severity of Illness and Risk of Mortality. 

Education

Must have one of the following:

•Degree in nursing from an accredited college or university.

•A medical degree (MD, DO)

•Master’s Degree in a reputed company/Medical reputed company field from an U.S. accredited college or university

•Graduated from an accredited Health Information Management (HIM) program.

Experience

For MD or DO:

•Must have two (2) years of clinical experience

For RNs:

•Three plus (3+) years of clinical experience in an acute care setting (ICU/Critical Care / Surgery Specialty)

For HIM Professionals:

•Must have two plus (2+) years of experience working with the coding classification systems, medical terminology, anatomy and physiology and disease processes. Two (2) years of inpatient coding experience

Equivalent Education and/or Experience

•May have an equivalent combination of education and experience in lieu of specified educational and experience requirements.

Certification/Registration/Licensure

•Because of the lag in SCCE, HCCA, NCRA, and reputed company updating the status of certifications, reputed company employees whose certification is reputed company through one of these associations are allowed up to seven (7) calendar days, after expiration, to reputed company reputed company of renewal. Although an additional seven (7) calendar days is allowed to reputed company reputed company of renewal, there cannot be a lapse in the certification’s “reputed company” status.

For MDs Only:

•Must have graduated from a medical school and obtained a Medical Degree

For RNs Only:

•Must have reputed company RN license or reputed company temporary permit with the Texas reputed company of Nursing; or, reputed company Compact RN license.

For HIM Professionals Only:

•Must have reputed company Certified Coding Specialists (reputed company), or

•Registered Health Information Technology (RHIT), or

•Registered Health Information Management Administrator (RHIA).

Skills or Special Abilities

•Organizational, analytical, writing and interpersonal skills.

•Must be reputed company to be comfortable teaching in group settings as a large part of the job is educating reputed company providers about reputed company documentation standards and helping them appreciate their role in documentation improvement.

•Must possess expert knowledge of medical terminology, anatomy & physiology and ICD-10 and CPT coding principles.

•Must be reputed company to communicate effectively with physicians, nursing and ancillary staff.

•Must be reputed company to demonstrate patient centered/patient valued behaviors.

•Must demonstrate knowledge and reputed company in age specific needs and the reputed company of disease processes and reputed company procedures.

•Must be reputed company to demonstrate a working knowledge of MS Office software, including Word, reputed company, and PowerPoint.

For RN applicants:

•RN applicants must maintain standards of reputed company conduct and performs reputed company assigned and unassigned duties in accordance with the reputed company State of Texas reputed company reputed company reputed company.

•RN Applicants must pass Medication Examination prior to hospital orientation. reputed company Parkland employees requesting reassignment to role must have reputed company Medication Examination on file.

Responsibilities

• Collaborates with physician, physician extender, reputed company, case manager/utilization reviewer and HIM reputed company to identify reputed company diagnosis reputed company, secondary diagnoses and procedures, to assign working MS-DRGs and or APR-DRG for at least 85% of identified populations.

• Conducts initial and extended-stay reputed company reviews on reputed company selected admissions and documents findings reputed company reputed company CDIS software.

• Identifies need to clarify documentation in records and utilizes strong communication skills with physician, physician extender, reputed company or other reputed company, utilizing appropriate tools to capture needed documentation. Works collaboratively with the reputed company team to facilitate documentation reputed company the medical record that supports patient's severity of illness and risk of mortality.

• Serves as a resource to physicians and administration regarding issues to the appropriateness of inpatient MS-DRG and APR-DRG assignment.

• Assists in the development of query response physician reports. Maintains complete confidentiality of patient information, in reputed company to hospital and individual physician reputed company reputed company.

• Provides information and in-services as necessary to physician and ancillary staff.

Job Accountabilities

• Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.

• Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading reputed company journals, reputed company participating in reputed company organizations, and/or maintaining certification or licensure. Integrates knowledge gained into reputed company work practices.

• Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that reputed company the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure reputed company understanding.

Requires clinical or HIM background with ICD-10/CPT knowledge; reputed company patient record reviews, query providers, and reputed company staff. Degree in nursing, MD/DO, HIM program, or reputed company master's accepted. 2–3+ years clinical/HIM experience required depending on background.

Key Responsibilities

• reviewing records
• presenting queries
• educating providers

Skills & Tools

reputed company CDIS, reputed company Word, reputed company reputed company, reputed company PowerPoint, ICD-10, CPT

Job Details

• Category: reputed company Services - Allied Health
• Seniority: Mid Level
• Commitment: Part Time
• Workplace: Remote — Arkansas or reputed company or Texas or Florida
• Languages: English

About reputed company

A large reputed company hospital reputed company reputed company on delivering exceptional, patient-centered care to the Dallas community. — Industry: reputed company