Clinical Documentation Specialist

Job description

Description Opportunity for Full Time Days Monday-Friday Will be on site: Clinical Documentation Specialist will ensure the overall quality and completeness of clinical documentation in patient medical records through extensive concurrent review, and concurrent interaction with physicians, care team members, case management, health information management and others as applicable. Monitors the documentation process and facilitates modifications to documentation to ensure clinical severity and intensity of service is documented to support the level of service and treatment rendered, to ensure accurate description of reasons for admission, patient severity, risk of mortality and conditions present on admission. ESSENTIAL DUTIES AND RESPONSIBILITIES: 1. Review inpatient medical records using EMR for identified payer populations on admission. 2. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation. 3. Works collaboratively with the coding staff to ensure documentation of principal diagnosis. 4. Facilitates modifications and improvements to clinical documentation. 5. Track successes and opportunities of the program by analyzing dat...