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Clinical Documentation Specialist
Location
Texas
Posted
51 days ago
Salary
0
Seniority
Senior
Job Description
Clinical Documentation Specialist
Sigma Systems
• Facilitating improvement in the overall quality and completeness of the medical record documentation • Providing support and expertise through comprehensive assessment and review of inpatient medical records • Ensuring accurate DRG assignment and obtaining appropriate documentation through interaction with physicians, patient caregivers, and health information management coding staff • Monitoring home health patients to ensure they meet CMS criteria for services • Proactive outreach to patients and making recommendations to primary care providers • Facilitating communication and coordinating care with healthcare providers and caregivers • Creating positive relationships with home health agencies as well as primary care clinicians
Job Requirements
- Bachelor's Degree in Nursing preferred
- Foreign or domestic Medical School Graduate (license not required), OR Graduate from a Physician's Assistant or RN Program
- 3-5 years of clinical experience required
- 2 years of home health experience preferred
- 2-3 years of managed care and/or care management experience preferred
- An RN license in the state of employment or compact is required
Benefits
- Health insurance
- 401(k) matching
- Flexible work hours
- Paid time off
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Role Description The CDI Specialist facilitates and obtains appropriate physician documentation for any patient clinical condition or procedure to support the appropriate severity of illness, expected risk of mortality, and complexity of care as documented in patient medical records. Extensive medical record review and interaction with physicians, nursing staff, other patient care givers and HIM coding professionals is done to ensure the documentation is complete and accurate. - Completes initial patient medical record review within 24-48 hours of patient's admission; completes subsequent reviews of patient's medical record reviews every 24-48 hours and enters review findings in CDE software system. - Assigns Principal diagnosis, CC/MCC (complication and comorbidity/major complication and comorbidity), evaluates for Severity of Illness (SOI) and Risk of Mortality (ROM) on all patients while in-house. Assigns working ICD-10-CM and PCS codes and DRG (Diagnosis Related Group) using encoder in CDE software. - Clarifies with physicians regarding missing, unclear, unsupported or conflicting health record documentation by requesting and obtaining additional documentation from physicians when needed. Face to face physician interaction and written clarifications are used. - Educates key healthcare providers such as physicians, nurse practitioners, allied health professionals, nursing and care coordination regarding clinical documentation improvement, documentation guidelines and the need for accurate and complete documentation in the health record. - Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine the working and final DRG assignment. Reviews DRG denial letters and writes denial appeal letters. - Collaborates with care coordination, nursing staff and other ancillary staff regarding interaction with physicians on documentation and to resolve physician clarifications prior to patient discharge. - Maintains and upholds all clinical documentation regulatory guidelines. - Formulates and submits timely, well prepared appeals for reconsideration by third party administrators (payors). Including supporting documented clinical evidence, Coding/CDE Guidelines and other regulatory standards/guidelines as appropriate. Works collaboratively with co-workers and management to effectively resolve root cause issues that impact payor contracts, hospital operations, or departmental to maintain reimbursement and minimize appeal requests and/or denials. Qualifications - Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, or Emergency Department experience. - Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations. - Ability to organize and present information clearly and concisely; excellent computer and keyboarding skills; high degree of prioritization skills. - Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences. Requirements - Current RN Licensure. - CRCR Required within 9 months of hire. Benefits - Bonus Incentives. - Paid Certifications. - Tuition Reimbursement. - Comprehensive Benefits. - Career Advancement.
Co-Founder & CEO – HealthTech, AI Clinical Documentation Compliance
FutureSightWe build world-class software companies with values driven founders.
• Set the venture's direction and lead its execution • Refine the ICP, pricing model, and product positioning • Lead pilots with compliance and revenue cycle leaders, convert them to paid engagements, and build the go-to-market motion • Partner with the FutureSight product and engineering team to ship V1 and iterate on user feedback • Lead the seed raise, supported by FutureSight's network and traction • Recruit and lead the founding team, and establish the cultural foundation of the company
Co-Founder & CEO – HealthTech, AI Clinical Documentation Compliance
FutureSightWe build world-class software companies with values driven founders.
• Set the venture's direction and lead its execution. • Refine the ICP, pricing model, and product positioning • Lead pilots with compliance and revenue cycle leaders, convert them to paid engagements, and build the go-to-market motion • Partner with the FutureSight product and engineering team to ship V1 and iterate on user feedback • Lead the seed raise, supported by FutureSight's network and traction • Recruit and lead the founding team, and establish the cultural foundation of the company
Co-Founder & CEO – HealthTech, AI Clinical Documentation Compliance
FutureSightWe build world-class software companies with values driven founders.
• Set the venture's direction and lead its execution • Refine the ICP, pricing model, and product positioning • Lead pilots with compliance and revenue cycle leaders, convert them to paid engagements, and build the go-to-market motion • Partner with the FutureSight product and engineering team to ship V1 and iterate on user feedback • Lead the seed raise, supported by FutureSight's network and traction • Recruit and lead the founding team, and establish the cultural foundation of the company


