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Mercy Cedar Rapids
Overview
The Clinical Documentation Specialist reviews medical records to ensure accurate reflection of patient conditions and services provided. They collaborate with physicians and the coding team to resolve documentation issues and manage denials related to medical necessity.
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Compensation
Salary not listed
Posted
8 days ago
Ascension
Apply diagnostic and procedural codes to patient health records and create APC/DRG assignments for claim processing. Conduct chart audits and query physicians to ensure documentation accuracy and regulatory compliance.
9 days ago
UMass Memorial Health
Collaborates with physicians and staff to ensure patient records accurately reflect the severity of illness and risk of mortality. Analyzes clinical status and treatment plans to identify and resolve gaps in medical documentation for coding and reimbursement purposes.
$87,277 - $157,082 / YEAR
17 days ago
American Addiction Centers
Facilitate modifications of clinical documentation through interaction with physicians to ensure accurate capture of clinical severity and risk of mortality. Perform chart reviews and provide ongoing education to the healthcare team regarding coding and reimbursement issues.
$38 - $57 / HOUR
25 days ago
CVS Health
The Medical Scribe supports primary care providers by documenting patient encounters in real-time and preparing after-visit summaries. They also assist with clinical documentation improvement and provide administrative support to the care team.
$17 - $31 / HOUR
28 days ago
29 days ago
Omega Healthcare Solutions
The specialist is responsible for improving the quality and completeness of clinical documentation within electronic health records through collaboration with physicians and coding staff. They ensure documentation accuracy to facilitate compliant coding and meet regulatory standards for reporting outcomes.
Day Kimball Healthcare
The CDI Specialist ensures accurate physician documentation to support severity of illness and risk of mortality in patient medical records. This involves reviewing records, collaborating with healthcare providers, and partnering with coding professionals to determine final DRG assignments.
$80,000 / YEAR
1 month ago
GBMC HealthCare
The CDI Nurse will collaborate with coding and clinical teams to enhance diagnosis coding accuracy for risk adjustment and reimbursement optimization across outpatient practices. Key duties include leading pre-visit documentation reviews and contributing to the strategic maintenance of accurate patient problem lists in the EMR.
$73,466 - $126,056 / YEAR
AAPC
Accurately code medical records for all inpatient services while following current ICD-10-CM and PCS guidelines. Collaborate with Clinical Documentation Improvement specialists to reconcile DRGs and ensure all project deadlines are met.
Unity Health
The Clinical Documentation Improvement Specialist facilitates modifications to medical records through concurrent interaction with physicians to ensure accurate clinical severity and billing levels. They evaluate documentation, lab results, and treatment plans to support the level of service rendered.
Virtua Health
Codes and abstracts hospital medical records across various departments while ensuring accuracy according to federal and state guidelines. Collaborates with medical staff and clinical documentation improvement teams to clarify documentation and maintain compliance.
$29 - $45 / HOUR
The HIM Coder is responsible for accurately coding and abstracting hospital medical records for various departments using federal and state guidelines. They collaborate with medical staff and clinical documentation improvement teams to ensure documentation clarity and accurate DRG assignment.
Neuropsychiatric Hospitals
The HIM Coder is responsible for coding inpatient medical records using ICD-10-CM and ensuring accurate MS-DRG assignment. They also perform clinical documentation improvement, analyze medical records for quality assurance, and assist with general HIM department tasks.
Genesis Administrative Services LLC
The Clinical Documentation Improvement Specialist oversees and ensures the accuracy of High Nursing Facility Level (HNF) clinical documentation for regulatory compliance and reimbursement. They collaborate with interdisciplinary teams to audit charts, educate staff, and manage acuity level communication with Managed Care Organizations.
The Clinical Documentation Improvement Specialist is responsible for overseeing and ensuring the accuracy of clinical documentation for regulatory compliance and reimbursement. They collaborate with interdisciplinary teams to audit charts, monitor resident conditions, and educate staff on documentation standards.
The Clinical Documentation Improvement Specialist oversees clinical documentation to ensure accuracy, regulatory compliance, and proper reimbursement for resident care. They collaborate with interdisciplinary teams to audit charts, educate staff, and manage acuity levels according to state guidelines.
LCMC Health
The Senior Coder is responsible for accurately assigning diagnosis and procedure codes, MS-DRGs, and APCs while validating charges against health record documentation. They also collaborate with clinical staff and physicians to resolve documentation issues and ensure compliance with coding and reimbursement regulations.
Sanford Health
The role involves reviewing inpatient clinical documentation, procedural information, and diagnostic results to accurately apply ICD-10-CM and PCS codes for various reporting and compliance purposes. This requires using professional coding training and clinical acumen to assign codes according to Official Coding Guidelines and organizational standards.
$22 - $35 / HOUR
2 months ago
Northwell
The Coding Auditor conducts audits to optimize diagnosis related groupings and develops coding instruction classes for staff. They are responsible for preparing coding guidelines, implementing changes, and monitoring case mix index performance.
$66,300 - $98,500 / YEAR
