clinical documentation improvement specialist

Tidelands Health

<div>
 Employee Type:
 
 
 Regular
 
 
 Work Shift:
 
 
 Day - 8 hour shift (United States of America)
 
 
 
 Join Team Tidelands and help people live better lives through better health!
 
 
 
 
 Clinical Documentation Improvement Specialist (RN) (3419)
 
 
 
 Are you passionate about quality and committed to excellence? Consider joining our Tidelands Health team. As our region's largest health care provider, we are also one of our area's largest employers. More than 2,500 team members at more than 70 Tidelands Health locations bring our healing mission to life each day.
 
 
 
 A Brief Overview
 
 
 
 The Clinical Documentation Improvement Specialist (RN) is a hybrid role that combines the expertise of clinical documentation improvement (CDI) and outpatient Hierarchical Condition Category (HCC) coding. This position will report to the Outpatient CDI Program Manager. This position focuses on improving the accuracy, quality, and completeness of clinical documentation in outpatient medical records while ensuring compliance with coding guidelines. The specialist will work collaboratively with providers, coding teams, and other healthcare professionals to facilitate accurate coding, improve risk capture, and optimize reimbursement while reflecting the true severity of illness and care provided.
 
 
 
 Education Qualifications
 
 
 
 <ul>
 <li>
 BSN and a minimum of five years clinical nursing experience Required
 
 
 </li>
 </ul>
 
 Experience Qualifications
 
 
 
 <ul>
 <li>
 At least 3 or more years' experience either in the clinical field (RN), CDI field, or coding field Required
 </li>
 <li>
 Experience in an outpatient or acute care setting Required
 </li>
 <li>
 1 or more years' experience in HCC/Risk Adjustment Preferred
 </li>
 <li>
 Minimum of 3 years of experience in clinical documentation improvement, outpatient Hierarchical Condition Category (HCC), or a combination of both Preferred
 
 
 </li>
 </ul>
 
 Skills And Abilities
 
 
 
 <ul>
 <li>
 Strong clinical experience and critical thinking skills required
 </li>
 <li>
 Extensive knowledge of patient care, and knowledge of clinical measurement, tools, and clinical outcomes
 </li>
 <li>
 Ability to establish cooperative, working relationships with diverse groups and individuals, medical staff and other healthcare disciplines
 </li>
 <li>
 Ability to work independently, be resourceful, and possess strong organizational skills
 </li>
 <li>
 Ability to communicate effectively with physicians and other clinical staff; be courteous and professional
 
 
 </li>
 </ul>
 
 Licenses and Certifications
 
 
 
 <ul>
 <li>
 Registered Nurse - South Carolina Department of Labor, Licensing and Regulation Required
 </li>
 <li>
 Certified Professional Coder - American Academy of Professional Coders within 1 Year Required or
 </li>
 <li>
 Certified Coding Specialist - American Health Information Management Association within 1 Year Required or
 </li>
 <li>
 Certified Clinical Documentation Specialist - Association of Clinical Documentation Integrity Specialist within 1 Year Required
 
 
 </li>
 </ul>
 
 Physical Demand
 
 
 
 Light Physical Demand
 
 
 The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a contract for employment nor a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform tasks other than those specifically presented in this description.
 
 
 Tidelands Health is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
 
 
 Tidelands Health is an equal opportunity employer (EOE). Tidelands Health does not discriminate against employees or applicants for employment on the basis of race, color, creed, religion, age, national origin, disability, marital status, veteran status, gender, genetic information, familial status, or any other legally protected status.
</div>

Outpatient CDI Specialist (RN)

Valley Medical Center

<div></div><div><div><div><ul><li><h6 class="jobSectionHeader">Job Title:</h6>
 Clinical Documentation Specialist
</li><li><h6 class="jobSectionHeader">Req:</h6>
 2026-0293
</li><li><h6 class="jobSectionHeader">Location:</h6>
 VMC Main Campus
</li><li><h6 class="jobSectionHeader">Department:</h6>
 Health Information Mgmt
</li><li><h6 class="jobSectionHeader">Shift:</h6>
 Days
</li><li><h6 class="jobSectionHeader">Type:</h6>
 Full Time
</li><li><h6 class="jobSectionHeader">FTE:</h6>
 1
</li><li><h6 class="jobSectionHeader">Hours:</h6>
</li><li><h6 class="jobSectionHeader">City State:</h6>
 Renton, WA
</li><li><h6 class="jobSectionHeader">Salary Range:</h6>
 Min $94,894 - Max $142,341/annual DOE</li></ul></div></div> 
 
 
 
Job Description:
VALLEY MEDICAL CENTER

JOB DESCRIPTION

The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.

TITLE: Clinical Documentation Specialist RN

JOB OVERVIEW: The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.

DEPARTMENT: Health Information Management

HOURS OF WORK: Days Monday - Friday.

RESPONSIBLE TO: Manager, Clinical Documentation Improvement

PREREQUISITES:
<div>
<ul><li>Current unrestricted WA State Registered Nurse license, required.
</li></ul>
<ul><li>Bachelor's degree in Nursing, preferred.
</li></ul>
<ul><li>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
</li></ul>
<ul><li>Pass a pre-hire Clinical Exam with a minimum score of 70%
</li></ul>
<ul><li>Effective communication with Providers
</li></ul>
</div>QUALIFICATIONS:
<div>
<ul><li>Knowledge of hospital clinical practice standards for physicians and other health care providers.
</li></ul>
<ul><li>Knowledge of ancillary service departments, quality control and safety standards.
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills.
</li></ul>
<ul><li>Familiarity with health care audit and research design.
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease process.
</li></ul>
<ul><li>Functional knowledge of DRG coding systems.
</li></ul>
<ul><li>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
</li></ul>
<ul><li>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
</li></ul>
<ul><li>Meet productivity guidelines.
</li></ul>
<ul><li>Ability to learn/develop the skills necessary to perform and meet goal standards
</li></ul>
<ul><li>Organizational, analytical, writing, and interpersonal skills
</li></ul>
<ul><li>Dependable, self-directed, and pleasant
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease Process
</li></ul>
<ul><li>Basic Computer skills - familiarity with Windows based software programs
</li></ul>
<ul><li>Knowledge of regulatory environment
</li></ul>
<ul><li>Understand and support documentation strategies (upon completion of training)
</li></ul>
<ul><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)
</li></ul>
</div>UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:

See Generic Job Description for Administrative Partner.

PERFORMANCE RESPONSIBILITIES:

A. Generic Job Functions: See Generic Job Description for Administrative Partner.

B. Essential Responsibilities and Competencies
<div>
<ul><li>Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.
</li></ul>
<ul><li>Accurate and timely record review.
</li></ul>
<ul><li>Recognize opportunities for documentation improvement.
</li></ul>
<ul><li>Initiates severity worksheet for inpatients.
</li></ul>
<ul><li>Formulate clinically credible documentation clarifications.
</li></ul>
<ul><li>Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
</li></ul>
<ul><li>Effective and appropriate communication with physicians.
</li></ul>
<ul><li>Timely follow up on all cases and resolution of those with clinical documentation clarifications.
</li></ul>
<ul><li>Communicates with HIM staff and resolves discrepancies.
</li></ul>
<ul><li>Accurate input of data for reconciliation of case.
</li></ul>
<ul><li>Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.
</li></ul>
<ul><li>Identify any barriers to completion of documentation goals with appropriate interventions.
</li></ul>
<ul><li>Review of regulations and coding guidelines through seminars, meetings, and materials.
</li></ul>
<ul><li>In cooperation with the director of PFS/HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.
</li></ul>
<ul><li>Maintains confidentiality of all accessible patient financial or medical records information.
</li></ul>
<ul><li>Demonstrates the awareness of the importance of cost containment for the department. Provide suggestions regarding process or quality improvement opportunities to department manager.
</li></ul>
<ul><li>Other duties as assigned to facilitate accurate, timely patient account management.
</li></ul>
</div>Date Created: 5/18, updated 7/22

Grade: NC11

FLSA: E

Cost Center: 8490 

Job Qualifications:
PREREQUISITES:
<div>
<ul><li>Current unrestricted WA State Registered Nurse license, required.
</li></ul>
<ul><li>Bachelor's degree in Nursing, preferred.
</li></ul>
<ul><li>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
</li></ul>
<ul><li>Pass a pre-hire Clinical Exam with a minimum score of 70%
</li></ul>
<ul><li>Effective communication with Providers
</li></ul>
</div>QUALIFICATIONS:
<div>
<ul><li>Knowledge of hospital clinical practice standards for physicians and other health care providers.
</li></ul>
<ul><li>Knowledge of ancillary service departments, quality control and safety standards.
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills.
</li></ul>
<ul><li>Familiarity with health care audit and research design.
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease process.
</li></ul>
<ul><li>Functional knowledge of DRG coding systems.
</li></ul>
<ul><li>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
</li></ul>
<ul><li>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
</li></ul>
<ul><li>Meet productivity guidelines.
</li></ul>
<ul><li>Ability to learn/develop the skills necessary to perform and meet goal standards
</li></ul>
<ul><li>Organizational, analytical, writing, and interpersonal skills
</li></ul>
<ul><li>Dependable, self-directed, and pleasant
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease Process
</li></ul>
<ul><li>Basic Computer skills - familiarity with Windows based software programs
</li></ul>
<ul><li>Knowledge of regulatory environment
</li></ul>
<ul><li>Understand and support documentation strategies (upon completion of training)
</li></ul>
<ul><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</li></ul></div></div>

Clinical Documentation Specialist

Ascension

<div>We Are Hiring:
<div>
Location: Remote</div><div>
Facility: Ascension Wisconsin Hospitals</div><div>
Department/Specialty: Clinical Integrity Documentation</div><div>
Schedule: Days | Full Time</div><div>
Salary Range: $79,511.52-$110,834.59</div>
What You Will Do:
<div>
Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.</div><ul><li>
Complete admission reviews and assign a working Diagnosis Related Group. Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.</li><li>
Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.</li><li>
Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.</li><li>
Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.</li></ul>
What You Will Need:
<div>
Licensure / Certification / Registration:</div><ul><li>
One or more of the following required:<ul><li>
Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.</li><li>
Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.</li><li>
Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.</li><li>
Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.</li><li>
Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.</li><li>
Licensed Registered Nurse credentialed from the Wisconsin Board of Nursing or current home state license for multi-state license recognition &quot;Compact State&quot; obtained prior to hire date or job transfer date.</li></ul></li></ul><div>
Education:</div><ul><li>
High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.</li></ul>
Additional Preferences:
<ul><li>5 or more years of nursing experience in ICU and/or Emergency Department</li><li>
Previous Clinical Documentation Specialist experience</li></ul>
Why Join Our Team:
<div>
Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you&rsquo;ll find an inclusive and supportive environment where your contributions truly matter.</div>
Equal Employment Opportunity Employer:

Equal employment opportunity employer
Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster.
Fraud prevention notice
Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system.
E-Verify statement<div>
Employer does not participate in E-Verify and therefore cannot employ STEM OPT candidates.</div>
Benefits:
<div>
Paid time off (PTO) 
Various health insurance options &amp; wellness plans 
Retirement benefits including employer match plans 
Long-term &amp; short-term disability 
Employee assistance programs (EAP) 
Parental leave &amp; adoption assistance 
Tuition reimbursement 
Ways to give back to your community</div><div></div><div> 
Benefit options and eligibility vary by position. Compensation varies based on factors including, but not limited to, experience, skills, education, performance, location and salary range at the time of the offer.</div></div>

Banner Health

<div>Department Name:
Coding-Acute Care Compl &amp; Educ
Work Shift:
Day
Job Category:
Revenue Cycle
Estimated Pay Range:
$29.11 - $48.51 / hour Banner Health is committed to pay equity and transparency. The posted compensation range is a reasonable estimate that extends from the lowest to the highest pay Banner Health in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. This range is based on possible base salaries and does not include the value of our total rewards package. Actual pay determined at offer will be based on years of relevant work experience, education, certifications, skills, and geographic location, along with a review of current employees in similar roles to ensure pay equity is achieved and maintained.
<div>Innovation and highly trained staff. Banner Health recently earned Great Place To Work&reg; Certification&trade;. This recognition reflects our investment in workplace excellence and the happiness, satisfaction, wellbeing and fulfilment of our team members. Find out how we&rsquo;re constantly improving to make Banner Health the best place to work and receive care.</div><div><div><div><div><div><div><div><div><div>
Interested in joining our Coding team? We have great opportunities, whether you&rsquo;re looking for entry-level or have been coding for years! Requirements for each position noted below. Not the right fit for you? Keep looking! We have a lot different teams with different focuses (Facility vs Profee).
In this position, you bring your 5 years of acute care inpatient coding background to a team that values growth and development! This is a Quality position, not a day-to-day coding production role but does require coding proficiency and recent Hospital Facility Coding experience. This position is task-production-oriented ensuring quality in the Inpatient Facility Coding department. If you have experience with DRG and PCS coding/denials/audits, we want to hear from you.
Schedule: Full time, Monday-Friday 8am-5pm during training. Flexible scheduling after completion of training.
Location: REMOTE, Banner provides equipment
Ideal candidate:
<ul><li>5 years recent experience in acute-care Inpatient facility-based medical coding (clearly reflected in your attached resume);</li><li>
DRG and PCS Coding, Auditing experience;</li><li>
Bachelors degree or equivalent;</li><li>
Must be currently certified through AAPC or Ahima, as defined in minimum qualifications below. Please upload a copy or provide certification number in your questionnaire.
</li></ul>This is a fully remote position and available if you live in the following states only: AK, AR, AZ, CA, CO, FL, GA, IA, ID, IN, KS, KY, MI, MN, MO, MS, NC, ND, NE, NM, NV, NY, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI &amp; WY.
Interested in joining our Coding team? We have great opportunities, whether you&rsquo;re looking for entry-level or have been coding for years! Requirements for each position noted below. Not the right fit for you? Keep looking! We have a lot different teams with different focuses (Facility vs Profee).</div></div></div></div></div></div></div></div></div>
Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care.
POSITION SUMMARY
This position is responsible for the interpretation of clinical documentation completed by the health care team for the health record(s) and for quality assurance in the alignment of clinical documentation and billing codes. Works with clinical documentation improvement and quality management staff to: align diagnosis coding to documentation to improve the quality of clinical documentation and correctness of billing codes prior to claim submission; to identify possible opportunities for improvement of clinical documentation and accurate MS-DRG, Ambulatory Payment Classification (APC) or ICD-10 assignments on health records. Provides guidance and expertise in the interpretation of, and adherence to, the rules and regulations for code assignment based on documentation for all levels of complexity to include accounts encountered in Banner&rsquo;s Academic, Trauma, high acuity and critical access facilities, as well as specialized services such as behavioral health, oncology, pediatric. Acts as subject matter expert regarding experimental and newly developed procedure and diagnostic coding.
CORE FUNCTIONS
1. Provides guidance on coding and billing, utilizing coding and billing guidelines. Demonstrates extensive knowledge of clinical documentation and its impact on reimbursement under Medicare Severity Adjusted System (MS-DRG),All Payer Group (APR-DRG) and Ambulatory Payment Classification (APC) or utilized operational systems. Provides explanatory and reference information to internal and external customers regarding coding assignment based on clinical documentation which may require researching authoritative reference information from a variety of sources.
2. Reviews medical records. Performs an audit of clinical documentation to ensure that clinical coding is accurate for proper reimbursement and that coding compliance is complete. Provides feedback on coding work and trends, and offers suggestions for improvement where opportunities are identified. Reviews accuracy of identified data elements for use in creating data bases or reporting to the state health department. If applicable, applies Uniform Hospital Discharge Data Set (UHDDS) definitions to select the principal diagnosis, principal procedure, complications and co morbid condition, other diagnoses, and significant procedures which require coding. Apply policies and procedures on health documentation and coding that are consistent with official coding guidelines.
3. Assists with maintaining system wide consistency in coding practices and ethical coding compliance. If applicable, initiates and follows through on physician queries to ensure that code assignment accurately reflects the patient&rsquo;s condition, treatment and outcomes. Identifies training needs for coding staff. Serves as a team member for internal coding accuracy audits and documents findings.
4. Acts as a knowledge resource to ancillary clinical departments, patient financial services and revenue integrity analysts regarding charge related issues, processes and programming. Participates in company-wide quality teams&rsquo; initiatives to improve coding and clinical documentation. Assists with education and training of staff involved in learning coding. Assists in creating a department-wide focus of performance improvement and quality management. Assists and participates with management through committees to properly educate physicians, nursing, coders, CDM&rsquo;s, etc. with proper and accurate coding based on documentation for positive outcomes.
5. Performs ongoing audits/review of inpatient and/or outpatient medical records to assure the use of proper diagnostic and procedure code assignments. Collaborates on DRG and coding denials, billing edits/rejections to provide coding expertise to resolve issues and support appropriate reimbursement. Proficiency in claims software to address coding edits and claim denials utilizing multiple platforms and internal tracking tools. Provides findings for use as a basis for development of coding education and audit plans.
6. Maintains a current knowledge in all coding regulatory updates, and in all software used for coding, coding reviews and health information management for the operational group. Identifies and collects data to allow for monitoring and evaluation of trends in DRG (MS/APR-DRG), APC, HCC, other Heath Risk Adjusted Factors, National Correct Coding Initiative (NCCI) and the effect on Case Mix Index by use of specialized software.
7. May code inpatient and outpatient records as needed. Works as a member of the overall HIMS team to achieve goals in days-to-bill.
8. Works independently under limited supervision. Uses an expert level of knowledge to provide coding and billing guidance and oversight for all Banner facilities and services they provide. Internal customers include but are not limited to medical staff, employees, and management at the local, regional, and corporate levels. External customers include but are not limited to, practicing physicians, vendors, and the community.
MINIMUM QUALIFICATIONS
Requires a level of education as normally demonstrated by a bachelor&rsquo;s degree in Health Information Management or experience equivalent to same.
Demonstrated proficiency in hospital coding as normally obtained through 5 years of current and progressively responsible coding experience required.
Requires Certified Coding Specialist (CCS) or Certified Inpatient Coder (CIC) or Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) or Certified Coding Specialist-Physician (CCS-P) or Registered Health Information Technologist (RHIT) or Registered Health Information Administration (RHIA) or other qualified coding certification in an active status with the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC).
Demonstrated proficiency in hospital coding as normally obtained through 5 years of current and progressively responsible coding experience required.
Must possess a thorough knowledge of ICD Coding and DRG and/or CPT coding principles, as recommended by the American Health Information Management Association coding competencies. Requires an in-depth knowledge of medical terminology, anatomy and physiology, plus a thorough understanding of the content of the clinical record. Extensive knowledge of all coding conventions and reimbursement guidelines across services lines, LCD/NCDs and MAC/FIs.
Extensive critical and analytical thinking skills required. Ability to organize workload to meet deadlines and maintain confidentiality. Excellent written and oral communication skills are required, as well as effective human relations skills for building and maintaining a working relationship with all levels of staff, physicians, and other contacts.
Must consistently demonstrate the ability to understand the Medicare Prospective Payment System, and the clinical coding data base and indices, and must be familiar with coding and abstracting software, claims processing tools, as well as common office software and electronic medical records software.
PREFERRED QUALIFICATIONS
Additional related education and/or experience preferred.
Anticipated Closing Window (actual close date may be sooner):
2026-09-05
EEO Statement:
EEO/Disabled/Veterans
Our organization supports a drug-free work environment.
Privacy Policy:
Privacy Policy</div>

Inpatient Facility HIMS Coding Quality Associate

White Oak Management, Inc.

Overview Join our dynamic healthcare team as an Assistant Director of Nursing / MDS Coordinator, where you will play a pivotal role in ensuring exceptional patient care and compliance with regulatory standards. This energetic position offers the opportunity to lead clinical documentation improvement initiatives, coordinate comprehensive assessments, and oversee medical records management within a fast-paced, multidisciplinary environment. Your expertise will directly impact patient outcomes, operational efficiency, and adherence to industry standards such as NCQA and HIPAA. If you thrive in a collaborative setting and possess a passion for nursing excellence and healthcare management, this role is your next career milestone!Duties<ul><li>This is an on-call role features an on-call rotation schedule.</li><li>Lead the development and implementation of the Minimum Data Set (MDS) assessments to ensure accurate and timely completion in compliance with federal regulations.</li><li>Coordinate interdisciplinary team efforts to optimize patient care planning, discharge planning, and clinical documentation improvement.</li><li>Oversee medical records management, ensuring accuracy, completeness, and confidentiality in accordance with HIPAA standards.</li><li>Utilize advanced EMR (Electronic Medical Record) systems such as Ecin, Epic, or PCC to review medical documentation, coding, and clinical data.</li><li>Conduct utilization review and utilization management activities to support appropriate resource allocation and reimbursement processes including Medicare and managed care programs.</li><li>Collaborate with nursing staff on CPT coding, ICD-9/10 coding, DRG assignment, and medical documentation review to enhance coding accuracy and reimbursement.</li><li>Facilitate training sessions on healthcare regulations, ICD coding updates, and documentation best practices for clinical staff.</li><li>Assist in case management activities like discharge planning for hospice care or outpatient services to ensure seamless patient transitions across care settings.</li></ul>Experience<ul><li>Proven experience in nursing leadership roles with a focus on MDS coordination or clinical documentation improvement within long-term care facilities or hospitals.</li><li>Extensive knowledge of Epic EMR systems used for medical records management.</li><li>Demonstrated expertise in ICD-10/ICD-9 coding, CPT coding, DRG assignment, and Medicare regulations related to inpatient and outpatient billing processes.</li><li>Strong background in managed care environments with familiarity in utilization review and utilization management processes.</li><li>Critical care experience preferred along with nursing home experience or hospital-based acute care exposure.</li><li>Familiarity with healthcare quality standards such as NCQA standards; experience supporting clinical documentation improvement initiatives is highly desirable.</li><li>Knowledge of physiology, anatomy, medical terminology, HIPAA compliance requirements, and health information management practices essential for success.</li><li>Excellent communication skills combined with the ability to train multidisciplinary teams on complex documentation procedures while maintaining a lively enthusiasm for continuous improvement. Embark on a rewarding career journey where your leadership enhances patient outcomes through meticulous documentation and innovative healthcare solutions!</li></ul>Pay: Up to $45.00 per hourBenefits:<ul><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: In person

Assistant Director of Nursing / MDS Coordinator

Baptist Health System KY & IN

<div>Summary
Job Description:
Baptist Health Medical Group is looking for an Ambulatory CDI Specialist to join our team! This is a remote work position that requires residency in KY or IN
<div><div><div><div><div><div><div><div><div>The BHMG Ambulatory CDI Specialist I is responsible for the evaluation of documentation utilizing their coding and clinical expertise to ensure specificity of coding and coding accuracy. They identify HCC diagnosis codes, ensure documentation accurately reflects the medical necessity and acuity of the patients. They provide guidance/education to the providers, medical assistants, practice managers and ancillary staff on clinical documentation best practices. Position requires a self-motivated, flexible, confident presenter that is able to travel and work remotely as well as attend internal meetings.
Minimum Education, Training, and Experience Required
<ul><li>2 years&rsquo; professional medical group coding experience
</li><li>Experience with:
<ul><li>ICD-10-CM coding principles and procedures,
</li><li>HCPCS, CPT, CPT II and modifier coding,
</li><li>CMS HCC, HHS HCC, Rx HCC coding and risk adjustment assignment as it relates to provider documentation,
</li><li>Knowledge of Microsoft Office (Outlook, PowerPoint, Excel)
</li></ul></li></ul><ul><li>Preferred Experience
<ul><li>HCC (CMS, HHS, Rx HCC) coding and risk adjustment assignment as it relates to provider documentation,
</li><li>Proficient experience with Epic and/or other major EMR vendor software, and
</li><li>Presenting education to coders, providers and/or other caregivers.
</li><li>Clinical experience a plus
</li></ul></li></ul>Certification/Licenses:
<ul><li>Active Certification Required:
<ul><li>Certified Professional Coder (CPC)
certification or Certified Coding Specialist-Physician based (CCS-P) or equivalent
certification from AAPC, AHIMA or other
acceptable professional organization.
</li></ul></li><li>A minimum of one additional advanced certification, required within one year of hire.
<ul><li>CRC = Certified Risk Adjustment Coder (certification)
</li></ul></li></ul></div></div></div></div></div></div></div></div></div>Work Experience
Education
<h3 class="jobSectionHeader">If you would like to be part of a growing family focused on supporting clinical excellence, teamwork and innovation, we urge you to apply now!
</h3><h3 class="jobSectionHeader">Baptist Health is an Equal Employment Opportunity employer.</h3></div>

BHMG Ambulatory CDI Specialist

Trinity Health

<div>
 
 Employment Type
 
 
 
 Full time
 
 
 
 Shift
 
 
 
 Day Shift
 
 
 
 Description
 
 
 
 This is a M-F, 8a-5p remote position that requires certification. For the Holy Cross Medical Group this individual performs charge entry, charge approvals, and/or quality charge reviews; including but not limited to, appending modifiers and checking clinical documentation. Works closely with Revenue Integrity staff and providers to educate on improved documentation to support coding. Neurosurgery experience is highly preferred. CPC license is REQUIRED.
 
 
 
 What You Will Do
 
 
 
 Responsible for coding and/or validation of charges for more complex service lines, advanced proficiencies in surgical or specialty coding practice.
 
 
 Review chart, including nursing notes, physician orders, progress notes, and surgical or specialty notes thoroughly to interpret and validate and/or extract all charges. Ensure each chart is complete according to specified guidelines. Ensure charges captured on the correct patient, correct encounter, correct date of service, with any required modifiers.
 
 
 Review documentation, abstracts data and ensure charges/coding are in alignment within AMA and Medicare coding guidelines. Ensure medical documentation and coding compliance with Federal, State and Private payer regulations. a. Perform coding functions, including CPT, ICD-10 assignment, documentation review and claim denial review b. Responsible for proofing daily charges for accuracy and clean claim submission c. Responsible for balancing charges and adjustments d. Maintain productivity standards e. Maintain compliance with regulatory requirements
 
 
 Responsible for denial coordination with Patient Business Service (PBS) centers, including analysis of clinical documentation, assisting in appeals, root cause analysis and tracking as needed. 6. Educates clinical staff on need for accurate and complete documentation to ensure revenue optimization and integrity.
 
 
 Educate clinical staff on need for accurate and complete documentation to ensure revenue optimization and integrity.
 
 
 Perform outpatient clinical documentation improvement review (acute only) as needed.
 
 
 Perform research on charges and communicate findings to intra and inter-departmental colleagues.
 
 
 Maintain a minimum productivity standard, based on service line and charge type; including but not limited to, chart review, charge extraction, E&amp;M level assignment and charge entry.
 
 
 
 Minimum Qualifications
 
 
 
 Other related responsibilities as assigned by manager.
 
 
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 High school diploma or equivalent combination of education and experience.
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 Minimum three (3) years of relevant coding and charge control work experience in a Hospital and/or Physician Practice environment and experience in revenue cycle, billing, coding and/or patient financial services.
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 Strong working knowledge of medical terminology, data entry, supply chain processes, hospital and/or Medical Group practice operations.
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 Licensure / Certification: CPC license required.
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 Neurosurgery experience preferred
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 Must possess a demonstrated knowledge of clinical processes, clinical coding (CPT, HCPCS, ICD-9/10, revenue codes and modifiers), charging processes and audits, and clinical billing. Strong understanding of various medical claim formats.
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 Knowledge of clinical documentation improvement processes strongly preferred.
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 Strong knowledge of Ambulatory Payment Classification (APC), and Outpatient Prospective Payment System (OPPS) reimbursement structures and pre-bill edits including Outpatient Coding Edits (OCE)/Correct Coding Initiative (CCI) edits and Discharged Note Final Billed (DNFB).
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 Ability to perform charge capture processes, including understanding technical integration of electronic medical record and the automation of charge triggers, and ability to investigate charge errors accordingly. Epic experience desired.
 
 
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 </ul>
 
 Position Highlights And Benefits
 
 
 
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 Comprehensive benefit packages available, including medical, dental, vision, paid time off, 403B, and education assistance.
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 Comprehensive benefits that start on your first day of work
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 Retirement savings program with employer matching
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 We serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.
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 We live and breathe our guiding behaviors: we support each other in serving, we communicate openly, honestly, respectfully, and directly, we are fully present, we are all accountable, we trust and assume goodness in intentions, and we are continuous learners.
 
 
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 </ul>
 
 Ministry/Facility Information
 
 
 
 <ul>
 <li>
 A member of Trinity Health, one of the largest multi-institutional Catholic health care delivery systems in the nation, Fort Lauderdale-based Holy Cross Hospital, dba Holy Cross Health, is a full-service, not-for-profit, Catholic, teaching hospital operating in the spirit of the Sisters of Mercy.
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 We are the only not-for-profit Catholic hospital in Broward and Palm Beach counties.
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 Through strategic collaborations and a commitment to being a person-centered, transforming, healing presence, the 557-bed hospital offers progressive inpatient, outpatient and community outreach services and clinical research trials to serve as our community&rsquo;s trusted health partner for life. We are committed to providing compassionate and holistic person-centered care.
 
 
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 </ul>
 
 Legal Info
 
 
 
 We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
 
 
 
 Our Commitment
 
 
 
 Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
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Coding Specialist - CPC Required

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