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Community First Medical Center
Overview
The Clinical Documentation Specialist ensures the quality and completeness of patient medical records through concurrent review and collaboration with physicians and care teams. They facilitate documentation improvements to accurately reflect patient severity, risk of mortality, and intensity of service.
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Compensation
$70,000 - $85,000 / YEAR
Posted
3 days ago
University of Southern California
The Clinical Documentation Specialist conducts concurrent and retrospective reviews of inpatient medical records to ensure accurate documentation of acute care services. This role involves working closely with physicians to improve the quality and completeness of clinical documentation.
$59 - $97 / HOUR
16 days ago
Memorial Health
Performs clinical reviews of patient records to evaluate acute care service utilization and supports medical necessity for reimbursement. Facilitates physician documentation and provides data for quality improvement initiatives.
$33 - $53 / HOUR
1 month ago
SAGIS PLLC
The coordinator manages administrative components of the hospital credentialing and privileging process for surgical pathologists. They ensure all physicians maintain active medical staff privileges and comply with regulatory requirements.
$18 - $20 / HOUR
Texas Children's Hospital
The specialist assigns and audits ICD-10-CM and CPT codes for various medical records to ensure accurate billing and regulatory compliance. They also provide feedback to education teams and providers while identifying diagnosis and procedure codes from electronic medical records.
Salary not listed
Piedmont Healthcare Inc.
The Specialty Coder is responsible for performing primary diagnosis and complex procedural coding for designated hospital service lines. They focus on reviewing detailed physician documentation to ensure accurate ICD-10 and CPT code assignments for high-priority inpatient and outpatient accounts.
2 months ago
The University of Kansas Health System
The Physician Documentation Assistant provides clerical support to physicians by transcribing documentation and performing order entry. They also monitor patient testing results and collaborate with the healthcare team to improve patient throughput.
CQ Partners
The primary duties involve documenting physician findings, transcribing impressions and plans into the Electronic Medical Record, and assisting physicians with patient care, procedures, and education. Responsibilities also include anticipating physician and patient needs to maintain patient flow and ensuring proper coding of encounters.
Connecticut Children's
This role involves identifying opportunities for physician documentation improvement to ensure patient conditions and care are accurately reflected, and working closely with physicians and other providers to clarify documentation and resolve discrepancies. The specialist also collaborates continuously with the hospital Inpatient Coding team and stays current with coding guidelines and documentation standards to support the CDI program.
3 months ago
INSIGHT Surgical Hospital
The specialist analyzes physician documentation from Emergency Department and Outpatient Observation records to assign principal and secondary diagnoses and procedures using ICD-CM, CPT, and HCPCS coding systems and applicable modifiers. Duties include consulting reference materials, interpreting bundling guidelines, collaborating on billing issues, and consistently meeting quality and productivity standards.
The coder provides high-level technical expertise by analyzing physician documentation in health records to determine principal and secondary diagnoses and procedures, assigning appropriate codes, MS-DRGs, POAs, SOIs, ROMs, and APCs using encoder software and established guidelines. Essential functions include proficiently navigating health records, consulting references, collaborating on billing issues, interpreting bundling guidelines, and consistently meeting quality and productivity standards.
UF Health
The specialist is responsible for improving inpatient clinical documentation by concurrently reviewing medical records to ensure accuracy based on clinical evidence and ICD-10-CM coding guidelines. This involves identifying documentation enhancement opportunities and querying physicians for clarification to accurately reflect the patient’s severity of illness and risk of mortality.
The specialist is responsible for improving inpatient clinical documentation by concurrently reviewing medical records to ensure accuracy based on clinical evidence and ICD-10-CM coding guidelines. This involves identifying documentation enhancement opportunities and querying physicians to support more specific and accurate diagnoses.
Orlando Health
The Clinical Documentation Excellence I Registered Nurse conducts initial and follow-up concurrent reviews across hospitals to clarify documentation for accurate reflection of patient acuity and level of care. This involves coordinating with other departments, identifying missing documentation supported by clinical indicators, and submitting clarifications to medical staff when necessary.
