OVERVIEW

The Clinical Documentation Improvement Specialist plays a crucial role in enhancing the quality and accuracy of clinical documentation within healthcare settings. This position focuses on ensuring that medical records reflect the true complexity of patient care, which is essential for appropriate reimbursement and quality reporting. The ideal candidate will possess a strong understanding of medical terminology, coding systems, and documentation standards across various care settings, including home care, hospice care, and nursing homes.

EXPERIENCE

• Proven experience in medical records management or clinical documentation improvement is preferred.
• Familiarity with home care, hospice care, nursing home operations, and discharge planning processes is advantageous.
• Knowledge of ICD-9 coding systems and DRG methodologies is essential for success in this role.
• Experience with utilization review processes will be beneficial for assessing service appropriateness.
• Strong analytical skills with attention to detail are necessary for effective documentation review.
• Excellent communication skills are required to facilitate collaboration with healthcare providers and educate staff on documentation standards.
  This position offers an opportunity to make a significant impact on patient care quality through improved clinical documentation practices.
  Job Type: Contract
  Pay: $61.00 per hour
  Work Location: Remot

• Review clinical documentation to ensure accuracy and completeness in accordance with regulatory requirements and best practices.
• Collaborate with healthcare providers to clarify and improve documentation related to patient diagnoses, treatments, and outcomes.
• Analyze medical records for compliance with ICD-9 coding guidelines and DRG assignments.
• Conduct utilization reviews to assess the appropriateness of services provided and ensure adherence to managed care protocols.
• Participate in discharge planning processes to ensure comprehensive documentation that supports continuity of care.
• Provide education and training to clinical staff on effective documentation practices and the importance of accurate record-keeping.
• Stay updated on changes in regulations, coding standards, and best practices related to clinical documentation improvement.