Job Description

Job Description

Job Description

HEALTH INFORMATION MANAGEMENT SERVICES

Clinical Documentation Improvement Specialist

Full Time - 80 hrs/pay

M-F 8:00am to 4:30pm

Full Benefits

Scheurer Health, a rural critical access hospital, is seeking a full-time Clinical Documentation Improvement Specialist (CDI)-Certified Coder. This position provides active concurrent/retrospective review, feedback, and education to clinical care providers to improve documentation of all conditions, treatments, and care plans within the health record to accurately reflect the condition of the patient and promote patient care.

Essential Functions

• Conduct initial and extended-stay concurrent reviews
• Demonstrate successful completion of ongoing proficiency and compliance
• Identifies co-morbidities and complications and document appropriately
• Queries the medical staff and other clinical caregivers
• Identifies potential quality, severity of illness, risk of mortality, hospital/physician profiling, and reimbursement issues or missing documentation
• Communicate documentation issues clearly and concisely
• Attempts to capture all potential secondary diagnoses
• Act as liaison between clinical care providers and coding professionals
• Identifies documentation issues and trends and reports them to the appropriate manager
• Interacts with coding team as documentation issues are identified
• Provides ongoing education to medical staff
• Monitor changes in laws, regulations, rules, and code assignment that impact documentation and reimbursement

Minimum Requirements

• Required Certification(s): CPC, CCS, RHIT, RHIA, or equivalent AAPC/AHIMA certification.
• Minimum of 3 years of coding experience in Critical Access Hospital and/or physician practice settings.
• Demonstrates knowledge of CMS guidelines, payer policies, and regulatory compliance specific to coding and documentation.
• Experience with EMR/EHR systems, clinical workflows, and medical record review.
• Ability to educate and engage clinical staff in a collaborative, non-punitive manner.
• Strong analytical, communication, and presentation skills.

Benefits

• Competitive Pay
• Health, Vision, Dental and Life Insurance
• Short-Term and Long-Term Disability Insurance
• 401k with matching funds

For questions regarding this position, please contact Kathy Johnston, HIMS Manager, or Lynn Abbe, HR Generalist. Please submit all employment applications online at . EEO/AA/Employer M/F/Disability/Vet

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