- 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 ongoing interaction with physicians, other patient caregivers, and medical records coding staff to ensure the clinical documentation properly captures information describing patients’ acuity, the severity of illness, and the 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 key resource for medical and other staff on interpretation and application of clinical documentation.
Skills: Two Years of Experience
Schedule Notes: This position is remote.
Department: CLIN DOC AND CODING QUALITY
Minimum Degree Required: Associate's Degree
Shift Timings: 10:00 AM - 6:00 PM EST
Hours Per Day: 8.00
Hours Per Week: 40.00
Days Per Week: 5.00
Job Type: Contract
Salary: $45.00 - $50.00 per hour
- 8 hour shift
- Day shift
- Monday to Friday
Ability to commute/relocate:
- New York, NY 10004: Reliably commute or planning to relocate before starting work (Required)
- This is a remote position
- Clinical Documentation Specialist: 2 years (Required)
- Nurse Practitioner (Required)
- RN (Required)
- Physician Assistant (Preferred)
- Active Ahima Certification Certified Coding Specialist (CCS) (Preferred)
Work Location: One location