Wellstar Health System · 3 hours ago
Clinical Documentation Specialist
Atlanta, GA
Full-time
Hybrid
Mid, Senior Level
5+ years expWellstar Health System is dedicated to enhancing the health and well-being of every person they serve. They are seeking a Remote Clinical Documentation Specialist (CDS) who will utilize strong clinical knowledge to improve the quality and completeness of clinical documentation in patient medical records, working collaboratively with healthcare professionals and coding teams to ensure accurate information is captured for appropriate reimbursement and patient outcomes.
FitnessHealth Care
Responsibilities
Reviews clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician
Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, mid-level providers, case management team, nursing team, other patient caregivers, and HIM coding team
Reviews medical records concurrent and/or prospective/retrospective to the patient visit to determine opportunities to query physicians regarding essential clinical documentation
Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart
Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned
Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population
Ensure queries are compliant, grammatically correct, concise and free of typographical errors
Provides appropriate follow up on all queries
Notifies onsite Regional CDI Manager immediately when queries are not answered. Provides all data necessary for onsite Regional CDI Manager to assist
Reconciles all appropriate records daily in CDI software tool to ensure appropriate reporting is generated
Maintains required daily/weekly/monthly metrics. Meets productivity standards
Participates in required onsite meetings, conference calls and Skype presentations
Adheres to departmental Policies and Procedures
Participates in assuring hospital compliance with Federal and State regulatory requirements
Submit ideas to improve work flow and increase productivity of his/her team to the CDI Regional Manager/Executive Director and perform any other duties as assigned. Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintain knowledge base of current medical terminology, procedures, medications and diseases to provide accurate patient record analysis
Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician, hospital and regulatory outcomes
Reviews data and trends to identify additional areas of opportunity
Provides input to core measure and other quality data initiatives regarding areas for investigation and education (PSI’s and HAC’s)
Identify and participate in opportunities to improve documentation, EPIC, and quality of care initiatives
Qualification
Required
Bachelor's Degree in nursing or other health-related field
Cert Clin Document Specialist 1.00 Required
Cert Coding Spec 1.00 Required
Cert Document Improvement Prac 1.00 Required
Reg Nurse (Single State) 1.00 Required
RN - Multi-state Compact 1.00 Required
One or more years working in an acute care setting as a Clinical Documentation Specialist (CDS)- Required
Minimum of five years of healthcare experience -Required
Self-directed with good written communication skills necessary to effectively communicate with physicians and other healthcare providers
Minimum MS Office (Word, Outlook, Excel and PowerPoint) knowledge and expertise is expected
Chart Review Experience Required
It is expected that all RN's are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Required
Preferred
Prior experience of working as a CDI/Coding auditor is preferred
Prior experience of working in inpatient case management or utilization review is preferred
Strong medical surgical and/or critical care background Preferred
Experience with care coordination/utilization management, coding/DRG, billing, auditing and various healthcare payers Preferred
Clinician preferred and/or CDIP/CCDS credential Preferred
EPIC Electronic Medical Record and CDI Software experience Preferred
Regulatory background and DRG reimbursement knowledge and strong understanding of coding methodologies and guidelines preferred
Company
Wellstar Health System
The largest health system in Georgia.
10001+ employees
H1B Sponsorship
Wellstar Health System has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (22)
2024 (18)
2023 (13)
2022 (14)
2021 (18)
2020 (12)
Funding
Current Stage
Late StageLeadership Team
Candice L. Saunders
President and CEO
Alan Muster
SVP Specialty Division
Recent News
BiometricUpdate.com
2025-10-28
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