Job Closed

This listing is no longer active.

Lake Regional Health System logo
Lake Regional Health System

Your comprehensive health care provider at the Lake of the Ozarks.

Outpatient Clinical Documentation Improvement Specialist

Medical writerMedical writerFull TimeRemoteSeniorTeam 1,001-5,000Since 1978Company SiteLinkedIn

Location

Ohio

Posted

18 days ago

Salary

0

Seniority

Senior

Associate DegreeExperience acceptedEnglish

Job Description

Outpatient Clinical Documentation Improvement Specialist

Lake Regional Health System

• Responsible for performing concurrent reviews of patient records to ensure complete, accurate, and specific clinical documentation. • Should have a comprehensive understanding of Coding Guidelines and are responsible for clarifying conflicting, incomplete, or imprecise documentation by actively seeking answers and actively educating providers. • Work to continuously improve clinical documentation to best reflect the care provided and corresponding reimbursement. • Responsible for improving the overall quality and completeness of clinical documentation. • Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and Physician Practice Coding staff to support that appropriate reimbursement, clinical severity of illness, and risk of mortality is captured for the level of service rendered to all patients. • Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and practice outcomes. • Educates all members of the patient care team on an ongoing basis.

Job Requirements

  • Must have an Associate’s degree in Healthcare, Nursing or related field, or equivalent combination of education & experience.
  • Must have training in medical terminology, anatomy, and physiology.
  • Must have training and certification in coding, or equivalent combination of education and experience.
  • Must possess a certification; Certified Documentation Expert Outpatient (CDEO), Certified Clinical Documentation Specialist-Outpatient (CCDS-O), or Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) with coding or clinical documentation integrity experience.
  • Must agree to obtain CDEO or CCS-O within first year of employment.
  • In-depth knowledge of medical record content.
  • In-depth knowledge of coding/classification systems (ICD & CPT) and associated coding guidelines.
  • Experience with compliant healthcare documentation, HCC coding requirements, alternate payment models in a multi-facility, revenue cycle experience.
  • Basic computer skills.
  • Should be knowledgeable in use of coding software (encoders).
  • Should be knowledgeable in LDC/NCD (or how to look this up) and Quality Measures.
  • Should be knowledgeable in coding guidelines.
  • Requires excellent observation skills, analytical thinking, problem solving, plus excellent verbal/ written and presentation skills.
  • Must have the ability to balance and juggle multiple tasks, projects, and requests; meet deadlines.
  • Ability to communicate effectively via remote Teams application.
  • Manual and finger dexterity.
  • Sitting for extended periods of time.
  • Ambulate to provider practices or group meetings, as needed.
  • Requires corrected vision and hearing to normal range.
  • Requires working under stressful conditions.
  • Excellent interpersonal skills in dealing with co-workers, providers, physicians and their office staff, Practice Mangers, and other Work Areas.

Benefits

  • Health insurance
  • Retirement plans
  • Paid time off
  • Flexible work arrangements
  • Professional development opportunities

Related Categories

Related Job Pages

More Medical writer Jobs

Full TimeRemoteTeam 10,001+Since 2013H1B Sponsor

• Prepares clinical and regulatory documents needed for the development of AbbVie drugs and/or devices. • Functions with a moderate degree of autonomy on draft materials, but relies on review by subject matter experts and more senior writers for verification. • Develops knowledge and understanding of submission strategies. • Coordinates the review, approval, and quality control of other functions involved in the production of clinical and regulatory projects. • Arranges and conducts review meetings with the team. • Produces and maintains clinical and regulatory documents focusing on quality and compliance and ensures delivery within project timelines. • Develops understanding of project management concepts and accepts greater responsibility for driving submission objectives. • Develops knowledge of US and international regulations, requirements, and guidelines pertaining to the preparation of regulatory documentation. • Understands and uses guidance associated with preparation of regulatory documentation. • Participates in execution of tactical process improvements. • Identifies and proposes solutions to resolve issues and questions arising during the writing process, including resolution or escalation as appropriate. • Works closely with leadership and R&D Quality Assurance to address inquiries and draft responses, supporting an inspection-ready approach.

Illinois
$96.5K - $183.5K / year
Job Closed
Cleveland Clinic logo

Clinical Documentation Specialist – I

Cleveland Clinic

The not-for-profit Cleveland Clinic was established in 1921 by four prominent doctors and provides a unique combination of clinical and medical care with academ

Medical writer18 days ago

• Provide education to providers and clinicians to ensure accurate documentation • Review for correct DRG, APC and HCC assignment • Conduct reviews of medical records for patients in outpatient settings • Query providers and medical team members to clarify clinical documentation

Ohio
Job Closed

Document Review Specialist

J. J. Keller & Associates, Inc.

J. J. Keller & Associates, Inc. is a North American organization providing innovative safety and regulatory compliance guidance and solutions to organizations across the U. S. and Canada. For over 70 years, organizations of all sizes have relied on J. J. Keller to help them create safe work environments for their employees and comply with ever-changing regulations.

Medical writer18 days ago

Role Description J. J. Keller has a REMOTE - Document Review Specialist opening in one of our fastest growing departments called Managed Services. This department is comprised of fleet and regulatory compliance experts who clients rely on to off-load the time consuming / complex tasks of managing driver safety and vehicle compliance. As a Document Review Specialist you will be responsible for auditing various documents on behalf of our clients in a metric driven environment. This position will also be responsible for translating documents from Canadian French to English. Job Responsibilities - Audits driver qualification documents and drug & alcohol information for clients. - Identifies discrepancies, checks systems for pertinent information, and enters information into applicable systems. - Works with Client Service Specialists to obtain and/or validate client information. Updates information in all applicable systems. - Maintains knowledge of the applicable local, state, and federal regulations that pertain to our service offerings. - Maintains confidentiality of client information under the FCRA, HIPAA, and other regulatory entities. Adheres to the department's data security policies pertaining to Personal Identification Information. Qualifications - Fluency in speaking, writing and reading French, Canadian French a plus. - High School Graduate or General Education Degree (GED). - 1+ years of experience in a general office setting. - In lieu, will consider a combination of experience and post-secondary education. - Experience in highly regulated industry a plus or ability to learn complex regulatory standards. - Must be proficient in the use of a PC and have the ability to navigate between multiple screens and computer programs. - Strong organizational skills and attention to detail. Requirements - Work is performed primarily in a standard office environment. - Work involves operation of personal computer equipment for extended periods of time. Benefits - $20 - $22/hr. - 17 days of PTO + 8 Paid Company Holidays + 1 Paid Floating Holiday - Annual Reviews + Merit Increases + Quarterly Bonus Program - New Hire On-the-Job Training - Medical + Dental + Vision Insurance - 401(k) with Employer Match + Company-funded Profit Sharing

United States
$20 - $22 / hour

Clinical Documentation Specialist

Singing River Health System

Singing River Health System is a community-focused healthcare provider serving the Mississippi Gulf Coast with hospitals in Pascagoula, Ocean Springs, and Gulfp

Medical writer18 days ago

Role Description The Clinical Documentation Specialist improves the overall quality and completeness of clinical documentation; facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the complexity and severity of illness for a complete and accurate level of service rendered to patients. - Analyzes the clinical status of patients, current treatment plans, and past medical history to identify potential gaps in clinical documentation. - Educates and serves as a clinical liaison to nursing staff and other clinicians on compliant documentation and accurate coding. - Reconciles DRG differences between the Coding staff and Clinical Documentation Specialist. - Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations. DISCLAIMER: This is not necessarily an exhaustive list of all responsibilities, duties, skills, efforts, requirements or working conditions associated with the job. While this intends to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks performed as assigned. Qualifications - High School graduate or equivalent required. - If Registered Nurse, must be a graduate from NLN School of Nursing; Bachelor of Science in Nursing required. Requirements - If Registered Nurse (RN), must hold current applicable license to practice in Mississippi. Current Mississippi RN license preferred. - If not a Registered Nurse, must be certified by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) as a: - Registered Health Information Administrator - Registered Health Information Technician - Certified Code Specialist - Certified Inpatient Coder - Must complete all requirements (including continuing education) to maintain certification. - CCDS preferred. - Must have de-escalation training completed by the end of position orientation (90 days); must have appropriate level of de-escalation training. - A Registered Nurse must have a minimum of two (2) years’ nursing experience in an acute-care facility. - Coders must have a minimum of two (2) years’ experience in ICD-9 CM and experience utilizing ICD-10 CM and ICD-10 PCS in an inpatient setting. - Must have working knowledge of the AHA Coding Clinic. - An understanding of the MS-DRG payment system is required. - An understanding of APR-DRG’s preferred. Benefits - Work is moderately active: involves sitting with frequent requirements to move about the office, move about the facility, and to travel to another facility within the SRHS service area. - Work involves exerting a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. - Work involves using many physical motions in performing daily work activities; subject to exposure of body fluids, sputum and tissues, which may carry the hazard of infectious disease. - Work involves using repetitive motions: substantial movements of the wrists, hands, and or fingers while operating standard office equipment such as computer keyboard. - Must be able to be active for extended periods of time without experiencing undue fatigue. - Must be able to work schedules assigned with the understanding that changes may be instituted according to the needs of the hospital for off days, shifts or weekends. Mental Demands - Must demonstrate keen mental faculties/assessment and decision making abilities. - Must demonstrate superior communication/speaking/enunciation skills to receive and give information in person and by telephone. - Must demonstrate strong written and verbal communication skills. - Must possess emotional stability conducive to dealing with high stress levels. - Must demonstrate ability to work under pressure and meet deadlines. - Attention to detail and the ability to multi-task in complex situations is required. - Must have the ability to maintain collaborative and respectable working relationships throughout SRHS and other organizations. Special Demands - Must possess superior customer service skills and professional etiquette. - Must possess proficient knowledge and ability to use a computer (must be keyboard proficient) and other office technology (i.e., telephone, fax, etc.), MS Outlook and Word. - Job requires traveling throughout the SRHS service area – with the employee providing his/her own transportation. - Work requires the ability to function independently, adapt to workload demands, set priorities, and understand and set goals. - Must possess highly developed organizational, planning and management writing skills. - Must understand the fundamentals of automated data processing, and be able to quickly gain a detailed understanding of complex computerized and non-computerized information.

Alabama + 8 moreAll locations: Alabama | Florida | Georgia | Louisiana | Mississippi | North Carolina | South Carolina | Tennessee | Texas