Title: Clinical Documentation Specialist
Location: Remote
Duration: 08 months
Duties:
1. Facilitates quality, completeness, accuracy, specificity and timeliness of
physician clinical record documentation through extensive medical record review, query process,
and effective communication with appropriate clinical and coding staff, and by utilizing computer
programs and systems.
2. Obtains appropriate physician documentation for clinical conditions or procedures through extensive
on-going interaction with physicians, other patient caregivers, and medical records coding staff to
ensure the clinical documentation properly captures information describing patients’ acuity, severity
of illness, and risk of mortality. Reflects the level of service delivered to patients is appropriate,
complete, and accurate and supports appropriate reimbursement for the level of service rendered to
all patients.
3. Reviews patient records for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, post admission
complications and procedures for accurate Diagnosis-Related Group (DRG) assignment
and Case Mix Index (CMI), risk of mortality, and severity of illness.
4. Queries physicians for incomplete, inconsistent, unclear or conflicting health record documentation
to clarify and resolve conflicting information in patient’s medical record prior to patient’s discharge
as key resource for medical and other staff on interpretation and application of
clinical documentation.
Skills:
Two Years Experience
Education:
1. Valid New York State license and current registration to practice as a Registered Professional Nurse (RN), Nurse Practitioner (NP), or Physician Assistant (PA), issued by the New York State Education Department (NYSED)
Job Type: Full-time
Salary: $50.00 - $55.00 per hour
Schedule:
- 8 hour shift
- Monday to Friday
Education:
- High school or equivalent (Preferred)
Experience:
- patient record: 2 years (Preferred)
License/Certification:
- Certified Nurse Practitioner/ RN/Physician Assistant (Preferred)
- Certified Coding Specialist (Preferred)
Work Location: Remote
Speak with the employer
+91 7014361561
