Clarity Partners · 1 month ago
Clinical Documentation Specialist
Chicago, IL
Full-time
Onsite
Entry, Mid Level
$40/hr - $60/hr
1+ years expClarity Partners is a recognized leader in the healthcare sector, seeking a Clinical Documentation Specialist to enhance the quality and accuracy of clinical documentation within the legal medical record. This role involves collaboration with healthcare professionals to ensure optimal reimbursement and accurate representation of patient conditions.
Information TechnologyMobile AppsSoftware
Responsibilities
Review inpatient medical records on a concurrent basis to assess the accuracy, completeness, and clarity of clinical documentation
Facilitate appropriate documentation in the medical record through extensive interaction with physicians, HIM, and coding staff to ensure optimal reimbursement and the highest level of SOI/ROM for services rendered
Initiate and manage provider queries to obtain missing, unclear, or conflicting documentation needed to support accurate diagnoses and treatments
Educate physicians and clinical staff on clinical documentation standards, coding guidelines, and reimbursement opportunities on an ongoing basis
Apply strong knowledge of medical terminology, clinical concepts, and procedures to identify documentation and reimbursement opportunities
Monitor acute care (inpatient) medical records for diagnoses, treatments, and follow-up entries to validate accurate documentation and coding
Collaborate with coding and quality teams to support accurate case mix index (CMI), quality metrics, and compliance with regulatory requirements
Participate in ongoing process improvement initiatives related to clinical documentation integrity
Qualification
Required
Bachelor's degree in Nursing, Health Information Management, or a related healthcare field required
License to practice as a Registered Nurse (any state); or credentialed as RHIA, RHIT, or CCS
CCDS (Certified Clinical Documentation Specialist – ACDIS) or CDIP (Certified Documentation Improvement Practitioner – AHIMA) credential required
Minimum of 1 year of acute care (inpatient) concurrent Clinical Documentation Specialist experience
Strong understanding of ICD-10-CM/PCS coding, DRG assignment, and reimbursement methodologies
Excellent communication and interpersonal skills with the ability to effectively educate and influence physicians and clinical staff
High attention to detail, strong analytical skills, and ability to work independently in a fast-paced environment
Preferred
3+ years of overall clinical, coding, or health information management experience in an acute care hospital setting preferred
Company
Clarity Partners
Clarity Partners is an information technology company specializing in custom application development and website development services.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Rodney Zech
Managing Partner
Recent News
2024-10-31
2024-05-23
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