clinical documentation improvement specialist

The University of Iowa

<div>The Clinical Documentation Improvement (CDI) program at UI Health Care has an opening for a full-time Clinical Documentation Specialist. The primary purpose of Clinical Documentation Improvement (CDI) is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation (Association of Clinical Documentation Improvement Specialists, ACDIS).
Clinical Documentation Specialists bridge the gap between the providers and hospital coders to clarify at-risk documentation to ensure accurate claim submission (American Health Information Management Association, AHIMA). CDI chart reviews include:<ul><li>
New acute inpatient admissions to the facility</li><li>
Identifies and re-reviews high priority charts every two days or as needed</li><li>
Retrospective reviews for query identification, documentation clarification, denials, or quality measures.</li><li>
Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e., AHRQ Patient Safety Indicators)</li></ul>
When provider documentation is illegible, incomplete, imprecise, inconsistent, conflicting, or unreliable the Clinical Documentation Specialist is expected to communicate (i.e., query) with the provider to obtain the necessary information to clarify the medical record (AHIMA, 2014).
The Clinical Documentation Specialist must hold a general proficiency within both the clinical and hospital coding skill sets. The Clinical Documentation Specialist provides the geometric mean length of stay (GMLOS) associated with the working DRG to identify the expected length of stay for acute inpatients.
The successful candidate will have:<ul><li>
A bachelor&rsquo;s degree in nursing or a master&rsquo;s degree in nursing (MNHP or MSN)</li><li>
An Iowa nursing license</li><li>
Three years of recent inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience</li><li>
Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.</li><li>
Applicants must upload a current resume and a cover letter that clearly address how they meet the listed required and desired qualifications of this position.</li></ul>
Initial training and onboarding will take place at the Healthcare Support Services Building (HSSB), 3231 Ridgeway Drive, located in Coralville, IA 52241. This position is eligible to participate in 100% remote work after the initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and the employee travel policy when working at a remote location.
Job Duties and Responsibilities:<ul><li>
Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient documentation, especially with providers, Health Information Management coding staff, hospital administration, and other patient caregivers.</li><li>
Demonstrate knowledge of MS-DRGs, APR-DRGs, documentation opportunities, clinical documentation requirements, and inpatient quality/safety metrics.</li><li>
Consistently attends huddles or rounds on units, as directed by department leadership.</li><li>
Provides consistent education on clinical documentation opportunities, hospital coding and/or reimbursement issues, as well as performance improvement methodologies to all members of the hospital community.</li><li>
Conduct record reconciliation and communicates effectively with hospital coding staff to assign an appropriate working DRG.</li><li>
Documents appropriately in the 3M&copy; Clinical Documentation Improvement module.</li><li>
Demonstrates an understanding of the importance of capturing all potential secondary diagnosis for coding purposes.</li><li>
Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.</li><li>
Comply with departmental standards regarding attendance, documentation, departmental workflows, continuous quality improvement and statistics, departmental policies and procedures, and the Code of Ethics.</li><li>
Effectively collaborates and respectfully communicates with fellow CDI team members, the hospital coding team, and quality-driven workgroups to ensure appropriate CDI practices and accurate application of coding/documentation principals.</li><li>
Actively participate in office and/or intradepartmental committees.</li><li>
Performs other projects or responsibilities as assigned.</li></ul>
Percent of Time: 100% (full-time)
Work schedule: Some flexibility between the hours of 7:00 AM and 5:00 PM, Monday through Friday.
Location: Initial onboarding and training will be completed at the Healthcare Support Services Building (HSSB), located at 3231 Ridgeway Drive in Coralville, IA 52241. This position is eligible to participate in 100% remote work after the initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and the employee travel policy when working at a remote location.
Salary level 5A. Starting salary will be based on applicant qualifications and related/relevant experience. To view the full pay range for salary level 5A: Professional and Scientific Pay Structures | University Human Resources - The University of Iowa.
Benefits Highlights: Fringe benefit package including paid vacation; sick leave; health, dental, life and disability insurance options; and generous employer contributions into retirement plans. Complete information regarding the full benefits package may be viewed at: https://hr.uiowa.edu/benefits.
<div>Required Qualifications:<ul><li>
A bachelor&rsquo;s degree in nursing or a master's degree in nursing (MNHP or MSN) is required.</li><li>
A current license to practice nursing in Iowa is required.</li><li>
Three years of recent (within the last 10 years) of inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience are required.</li><li>
Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.</li><li>
Professional written and verbal communication skills are required</li><li>
Demonstrates the ability to provide effective education in a variety of styles, including formal presentations.</li><li>
Proficiency with computer software applications (i.e., Microsoft applications) is required</li><li>
Demonstrates excellent interpersonal skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication is required.</li><li>
Demonstrated organizational, time management and problem-solving skills are required.</li></ul> 
Desired Qualifications:
<ul><li>Experience with performance improvement methodologies</li><li>
Experience improving and/or reviewing hospital quality/safety metrics</li><li>
Experience with data mining and/or data analytics</li><li>
Advanced certification (i.e., CCDS, CDIP, CPHQ)</li></ul>
Application Process:<ul><li>
To be considered for an interview, applicants must upload a current resume and a cover letter that clearly address how they meet the listed required and desired qualifications of this position.</li><li>
Job openings are posted for a minimum of 7 calendar days. Applications will be accepted until 11:59 PM on March 25, or on date of closing.</li><li>
Successful candidates will be required to self-disclose any conviction history and will be subject to a criminal background check.</li><li>
Professional references will be requested at a later step in the recruitment process.</li><li>
This position is not eligible for University of Iowa sponsorship for employment authorization.</li><li>
For questions, contact Heidi Bodensteiner at heidi-bodensteiner@uiowa.edu.</li></ul></div></div>

Clinical Documentation Specialist

TriHealth Inc.

<div><div>Join Our Team as a Clinical Documentation Specialist II! 
Join TriHealth as a Clinical Documentation Specialist II and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care. Apply today and be part of a team that is passionate about making a difference. 
We offer career growth opportunities, and a comprehensive benefits package. 
Location:<ul><li>
Remote</li><li>
This position requires in‑person attendance for scheduled onsite meetings; therefore, candidates must be located within the greater Cincinnati area.</li></ul> 
Work Schedule:<ul><li>
Full time</li><li>
Day shift</li><li>
No weekend or holiday rotation required</li></ul> 
Incentives &amp; Benefits:
We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement.
https://careers.trihealth.com/what-we-offer/benefits 
Job Requirements:<ul><li>
Bachelor's Degree in Nursing; Business, Education, HIM,</li><li>
CCDS - Certified Clinical Documentation Specialist</li><li>
Registered Nurse</li><li>
Advanced CDI certification if available</li><li>
Computer aptitude including but not limited to electronic medical record clinical documentation software programs, Word, Excel and PowerPoint</li><li>
5-7 years experience Clinical Nursing</li><li>
2-3 years experience Clinical Documentation</li></ul> 
Job Overview:<ul><li>
The Clinical Documentation Specialist II reports to the Clinical Documentation Department Manager. This team member assists with the delivery of clinical documentation strategies within the workplace that positively impact and drive change to attain organizational goals as well as maintain documentation standards as set by government and corporate guidelines, The Clinical Documentation Specialist II requires an advanced level of knowledge and experience for the successful management of clinical education in their specialty area, quality monitoring, documentation review and the ability to communicate this knowledge to team members throughout the organization, including Medical Staff Departments. They will serve as a subject matter experts in their specialty field which includes but is not limited to preparing and presenting a minimum of two educational topics each calendar year for the benefit of the medical staff, APNs, residents and/or team members as well as being responsible for specialty specific orientation to new team members or those who need refreshers. They will participate in peer interviews and leadership opportunities such as serving on committees, leading journal club or conducting a review course for team members interested in certification. This position requires a professional who works well independently but also values team and possesses excellent communication skills.</li></ul> 
Job Responsibilities:<ul><li>
Documentation Improvement - record review rate of at least 98%. Severity clarification rate of at least 25%. DRG shift clarification rate of at least 15%. 
Provides Informal education includes sharing with team members in assigned patient care area, inpatient coding department and clinical documentation team advanced or new strategies for capturing highest level of SOI/ROM, denial prevention, and determining PSIs. Documentation of informal education with physicians, APNs, residents on documentation strategies and their importance.</li></ul><ul><li> 
Maintains specialty certification and pursue advanced CDI certification within 1 year of certification becoming available. A minimum of two formal presentations per year on pertinent advanced CDI topics at monthly team meetings, resident or medical staff meetings.</li></ul><ul><li> 
Participates in department or hospital committees such as Stroke Committee, Task Force, etc., new team member specialty orientation leader or participating as part of the peer interview team. Other options include but are not limited to leading a department journal club or participating in a minimum of 10 hours of approved community service per year.</li></ul> 
Other Job-Related Information:
This position requires excellent verbal and written communication skills as well as proficiency in the electronic medical record, clinical documentation software, word, excel and power point. Expectation is that the Clinical Documentation Specialist 2 will prepare a minimum of two educational topics to be shared with team members at staff meetings and/or physicians at staff meetings on topics related to advanced CDI. 
Working Conditions: 
Climbing - Occasionally 
Concentrating - Consistently 
Continous Learning - Consistently 
Hearing: Conversation - Occasionally 
Interpersonal Communication - Consistently 
Kneeling - Occasionally 
Lifting &lt;10 Lbs - Occasionally 
Lifting 50+ Lbs - Rarely 
Lifting 11-50 Lbs - Occasionally 
Pulling - Occasionally 
Pushing - Frequently 
Reaching - Frequently 
Reading - Consistently 
Sitting - Frequently 
Standing - Frequently 
Stooping - Occasionally 
Thinking/Reasoning - Consistently 
Use of Hands - Consistently 
Color Vision - Consistently 
Walking - Frequently<div> 
TriHealth SERVE Standards and ALWAYS Behaviors: 
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: 
 
Serve: ALWAYS&hellip; 
<ul><li>Welcome everyone by making eye contact, greeting with a smile, and saying &quot;hello&quot;</li><li>Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist</li><li>Refrain from using cell phones for personal reasons in public spaces or patient care areas</li></ul></div><div> 
Excel: ALWAYS&hellip; 
<ul><li>Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met</li><li>Offer patients and guests priority when waiting (lines, elevators)</li><li>Work on improving quality, safety, and service</li></ul></div><div> 
Respect: ALWAYS&hellip; 
<ul><li>Respect cultural and spiritual differences and honor individual preferences.</li><li>Respect everyone&rsquo;s opinion and contribution, regardless of title/role.</li><li>Speak positively about my team members and other departments in front of patients and guests.</li></ul></div><div> 
Value: ALWAYS&hellip; 
<ul><li>Value the time of others by striving to be on time, prepared and actively participating.</li><li>Pick up trash, ensuring the physical environment is clean and safe.</li><li>Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.</li></ul></div><div> 
Engage: ALWAYS&hellip; 
<ul><li>Acknowledge wins and frequently thank team members and others for contributions.</li><li>Show courtesy and compassion with customers, team members and the community</li></ul></div> 
Job Keywords: Registered Nurse, Nurse, Clinical Documentation</div></div>

Clinical Documentation Specialist II

DelRicht Research

<div>
 Why DelRicht Research?
 
 
 Would you love to be a part of the cutting edge of healthcare and science innovation? Are you looking for a position that has sustainable opportunities for professional growth? We are a clinical research company dedicated to providing an excellent customer experience to all patients that participate in our clinical trials. Our clinical trials provide new treatment options for our patients and, ultimately, our goal is to get new medications and medical devices FDA approved. We are currently looking for a detail-oriented, confident Clinical Documentation Specialist to join our team.
 
 
 DelRicht Research has been recognized as one of New Orleans Top Workplaces for 2023, 2024, and 2025! This is a testament to our unwavering commitment to creating an exceptional work environment that fosters growth, collaboration, and employee satisfaction.
 
 
 NOTE: This is an onsite M-F position based at our New Orleans Corporate Headquarters location.
 
 
 Who We Are
 
 
 DelRicht is a clinical research company dedicated to providing an excellent customer experience to all patients that participate in our clinical trials. Our clinical trials provide new treatment options for our patients and ultimately our goal is to get new medications FDA approved! We hold our team members to a high standard of excellence and are looking for energetic, positive, quick learners to be a part of our team. Presently our network stretches across 18 sites throughout the United States.
 
 
 Clinical Documentation Specialist&rsquo;s Main Objective: This role is responsible for supporting the Quality Assurance (QA) team with process improvement initiatives, as well as training, and trend identification across the site network&rsquo;s clinics. The Clinical Documentation Specialist will maintain clinical trial data integrity to ensure site is audit ready at all times
 
 
 The Clinical Documentation Specialist Will Assist With Oversight And Maintenance Of Activities Related To The Conduct Of Clinical Trials At The Site Including But Not Limited To
 
 
 <ul>
 <li>
 Complete Quality Assurance (QA) chart reviews, ensuring consistency, accuracy, and timeliness
 </li>
 <li>
 Ensure that clinical trial protocols are being adhered to 100% of the time
 </li>
 <li>
 Coordinate, communicate and collaborate with clinical teams across our site network
 </li>
 <li>
 Maintain a working knowledge of FDA regulations, GCP/ICH guidelines, organizational SOPs, guidance documents and study protocols
 </li>
 <li>
 Detail plans for timely correction of electronic source errors
 </li>
 <li>
 Ensure both inter- and intra-site consistency in source completion
 </li>
 <li>
 Manage and report charting trends to leadership
 </li>
 <li>
 Assist with training for both clinical teams and the QA department
 </li>
 <li>
 Assist the QA manager with internal team training, developing and disseminating reports, and management tasks related to QA Coordinators
 
 
 </li>
 </ul>
 
 The Right Candidate Will
 
 
 
 <ul>
 <li>
 Required: Minimum 3 years of professional work experience
 </li>
 <li>
 Required: B.S or B.A from any accredited university in any degree
 </li>
 <li>
 Required: Experience in a clinic, quality assurance, project management, or similar healthcare environment
 </li>
 <li>
 Required: Familiarity with medical intake and terminology.
 </li>
 <li>
 Required: Experience with quality assurance (does not have to be in healthcare)
 </li>
 <li>
 Preferred: Experience working within cross-functional teams on process improvement initiatives
 </li>
 <li>
 Preferred: Familiarity with clinical charting and clinical reports.
 </li>
 <li>
 Be self motivated, energetic and positive
 </li>
 <li>
 Be a team player with excellent communication skills
 </li>
 <li>
 Be comfortable speaking to external and internal stakeholders and leaders
 </li>
 <li>
 Ability to work autonomously with a high level of self accountability
 </li>
 <li>
 Make sure client satisfaction is a primary focus and that the client is able to achieve and exceed their goals
 </li>
 <li>
 Believe in high quality and have a high standard of compliance to our study protocols
 </li>
 <li>
 Be remarkably organized with effective time management skills
 </li>
 <li>
 Be skilled at problem solving and solution focused
 </li>
 <li>
 Manage multiple tasks and clinical trials efficiently
 </li>
 <li>
 Accept ownership of tasks from inception through completion and assume responsibility for personal success
 </li>
 <li>
 Coffee drinkers preferred. Tea drinkers accepted.
 
 
 </li>
 </ul>
 DelRicht Research&rsquo;s Core Values: Production, Humility, Consistency
 
 
 
 Production
 
 
 
 <ul>
 <li>
 We deliver on our promises
 </li>
 <li>
 We have a bias towards action: we value independent problem solving
 </li>
 <li>
 We proactively over deliver: we can act without being told what to do and we always have new ideas that will be heard and will improve the company
 
 
 </li>
 </ul>
 
 Humility
 
 
 
 <ul>
 <li>
 We support each other relentlessly
 </li>
 <li>
 We always have enthusiasm: we exhibit passion and excitement about our work which leads to everyone having a &lsquo;can do&rsquo; attitude
 </li>
 <li>
 We embrace change: we are excited to always be growing and moving the organization forward which means change is the norm for us
 </li>
 <li>
 Coachable: we all love to learn, we are willing to be taught and will adapt quickly
 
 
 </li>
 </ul>
 
 Consistency
 
 
 
 <ul>
 <li>
 We always are able to execute: we get it right the first time and promote &lsquo;touch it once&rsquo; accuracy
 </li>
 <li>
 We have persistence: we demonstrate the tenacity and willingness to go the distance to get something done
 </li>
 <li>
 We are calm under pressure: we can maintain stable performance when under heavy pressure or stress
 
 
 </li>
 </ul>
 Our team comes first so here are some of the perks and benefits at DelRicht Research:
 
 
 <ul>
 <li>
 Comprehensive benefits - medical, dental &amp; vision
 </li>
 <li>
 Generous Paid Time Off that builds throughout your career with the company
 </li>
 <li>
 Even though we are in healthcare, we do not work nights, weekends or long day shifts (yes nurses love us)
 </li>
 <li>
 401K (including discretionary match/profit sharing)
 </li>
 <li>
 Exceptional quarterly bonus plan that clearly outlines your bonus potential per quarter and giving the team the visibility and control to maximize earnings by hitting team goals
 
 
 </li>
 </ul>
 Visit our website linked below to learn about our company and current clinical trials, see patient testimonials, and check out our careers page!
 
 
 Website: www.delrichtresearch.com
 
 
 Patient Testimonials: https://delrichtresearch.com/testimonials/
</div>

The University of Michigan

<div><h4 class="jobSectionHeader">Job ID: 53350</h4>
<h4 class="jobSectionHeader">Description:</h4>
<div>Positions Location: Lansing, MI<div> 
<h2 class="jobSectionHeader">
Job Description</h2>

General Purpose of Job:
The UMHP Clinical Documentation Specialist - Senior (CDS) serves as a subject matter expert in clinical documentation improvement and provider coding accuracy, for ambulatory Primary Care and Specialty Care services. This position provides advanced expertise, guidance, and education to physicians, APPs, and staff on documentation standards, CPT/ICD-10 and HCC coding, and compliance requirements. The CDS Senior focuses on analyzing complex documentation and coding issues, identifying opportunities for improvement, and coordinating with leadership on the development of best practices to ensure accurate charge capture.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Team members may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
<ul><li>Collaborates with key stakeholders on the design, implementation, education and evaluation of tools and resources to assist providers with efficient and effective documentation, accurate coding and charge capture opportunities. All coding edits and/or revisions including claim submission are the sole responsibility of the HIM and billing teams. All coding education will be approved by Compliance prior to implementation.</li>
<li>Provides partial coordination and project management of the Medical Group and Population Health&rsquo;s governance structure Councils, Committees and Offices.</li>
<li>Serves as a subject matter expert and supports fellow UMHP CDS team members.</li>
<li>Collaborates with key stakeholders on the facilitation and deployment of the UMHP CDS coding and documentation education strategy.</li>
<li>Collaborates with key stakeholders on the development of an upstream coding, documentation, charge capture, education approach focused on new departments and emphasizing new specialty areas to increase knowledge and establish sustainable best practices early on.</li>
<li>Provides support during the onboarding training and support for new physicians and APPs on documentation, coding and charge capture excellence, establishing a periodic check-in/assessment process and appropriate charge capture check-ins.</li>
<li>Collaborates with key stakeholder on communications with Primary Care site and Specialty Care service line leaders, physicians and APPs with regard to clinical documentation and medical coding for patient care services. Facilitates CDS interaction with site/service line provider champions.</li>
<li>Tracks ROI and collaborates with leadership on the preparation and analyzation of reports (ROI, Revenue Cycle, wRVU, etc.) to ensure operational alignment and buy-in and to provide feedback on provider and coding performance including state of documentation, charge capture and reconciliation.</li>
<li>In collaboration with the leadership and the UMHP CDS team, identifies ROI, documentation trends and priority areas/pain points to be shared with site/service line leadership to allow for clinician education. Prepares case and specific documentation examples/presentations to share at department meetings.</li>
<li>Reviews wRVU recovery data provides recommendations on areas to be prioritized.</li>
<li>Assists with UMHP and department initiatives to improve charge capture and reconciliation.</li>
<li>Supports the strategic development of outpatient charge capture optimization (i.e. professional clinical visits/services, surgeries, procedures and imaging studies), and facilitates change processes.</li>
<li>Identifies educational opportunities to improve and enhance learning. Maintains current with specialty coding updates, work processes, tools, and clinical and administrative applications necessary to perform job functions.</li>
<li>Serves as a resource on documentation requirements and ensures compliance with applicable laws and regulations at the direction of the internal audit team.</li>
<li>Builds and maintains positive working relationships throughout the organization that enable efficient leadership through projects involving change management or complex cross-departmental collaboration.</li>
</ul>
</div><div><h2 class="jobSectionHeader">Job Requirements</h2>
<div><div><div><div>General Requirements</div> <div>&bull; RHIT, RHIA, CCS, CCS-P, CPC or other professional HIM coding certificate &bull; EPIC or Revenue Cycle Certification &ndash; preferred &bull; Clinical Documentation certification &ndash; preferred
</div></div> 
<div><div>Work Experience</div> <div>&bull; At least five (5) years of experience with healthcare documentation, coding requirements, or revenue cycle coding experience &bull; At least one (1) year of experience as an educator or trainer in a healthcare setting &bull; Prior clinical experience &ndash; preferred &bull; Experience using EPIC &ndash; preferred
</div></div> 
<div><div>Education</div> <div>&bull; Associate degree in Business, Nursing, or related field; or equivalent experience in medical billing, coding, health information technology/management, health administration, business administration or another related field. &bull; Bachelor&rsquo;s degree in related field &ndash; preferred
</div></div> 
<div><div>Specialized Knowledge and Skills</div> <div>&bull; Extensive CPT and ICD-10 coding knowledge. &bull; Demonstrated experience providing documentation and coding education to providers. &bull; Excellent communication skills (verbal and written) to enable effective outcomes with the diverse complex clinical care teams. &bull; Ability to navigate the EHR to identify documents or review to provide accurate capture of clinical information. &bull; Medical terminology and clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate medical codes. &bull; Ability to work independently, self-motivated and an ability to adapt to the changing healthcare environment. &bull; Demonstrates attention to detail, proficiency in organizational skills and planning with and ability to juggle multiple priorities in a fast-changing environment. &bull; Proficiency in computer use including Microsoft Office Suite experience. &bull; Provide support to clinicians on navigating all functions of the EHR. &bull; Possess initiative-taking, strategic, innovating and out-of-the-box thinking. &bull; Exhibit an understanding of health care administration, health industry trends. &bull; Demonstrates leadership, independence, responsibility, accountability and good judgment. Ability to think strategically. &bull; Acts as a self-starter and demonstrate a willingness to take on new and challenging leadership roles, as well as non-leadership projects and deliverables. &bull; Accepts and respects diversity without judgment.
</div>
</div> 
</div></div></div>University of Michigan Health - Sparrow is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.
</div><h4 class="jobSectionHeader">Job Family</h4>
Management/Professional
<h4 class="jobSectionHeader">Requirements:</h4>
<div><div><div><div>Shift </div><div>Days
</div></div> 
<div><div>Degree Type / Education Level </div><div>Associate
</div></div> 
<div><div>Status </div><div>Full-time
</div></div> 
<div><div>Facility </div><div>Match Any
</div></div> 
<div><div>Experience Level </div><div>4-9 Years</div></div></div></div></div>

UMHP-CLINICAL DOCUMENTATION SPECIALIST SENIOR

Providence at Home with Compassus

<div>
 
 Company
 
 
 
 Providence at Home with Compassus
 
 
 *Active California RN license required. *
 
 
 
 Location:
 
 
 This is a remote position. Work schedule M- F 8am to 5pm PST. With a rotating schedule weekend and holidays.
 
 
 
 
 Position Summary
 
 
 
 The Clinical Documentation Specialist is responsible for the quality review of all OASIS documents and review of key elements of the Plan of Care to ensure CMS program compliance is met. The Clinical Documentation Specialist works closely with the Manager of Quality Improvement and Home Health leadership to promote regulatory compliance and excellent patient outcomes and reimbursement. The Clinical Documentation Specialist serves as a role model and OASIS expert to Home Health staff across the region.
 
 
 
 Position Specific Responsibilities
 
 
 
 <ul>
 <li>
 Works in a virtual team environment in a manner that promotes team cohesiveness, efficiency, and productivity.
 </li>
 <li>
 Responsible for the timely review and processing of Start of Care, Resumption of Care, Recertification, and Significant change in Condition Home Health OASIS Assessment documents and key elements of the Plan of Care.
 </li>
 <li>
 Collaborates with leadership to analyze performance trends in OASIS accuracy; assists in determining learning needs for clinical staff.
 </li>
 <li>
 Educates and provides feedback to clinical staff in regard to correct completion of OASIS documents.
 </li>
 <li>
 Reviews of all OASIS data items and ensures accuracy of OASIS based outcome measures to reflect accurate Home Health Quality of Care Star rating and Value Based Purchasing OASIS Based component of TPS.
 </li>
 <li>
 Ensures Regulatory compliance with all OASIS conventions.
 </li>
 <li>
 Ensures timely processing of all OASIS documents to meet CMS guidelines and CMS billing requirements.
 
 
 </li>
 </ul>
 
 Education And/or Experience
 
 
 
 <ul>
 <li>
 Required - Ability to align work schedule with Pacific Time Zone business hours.
 </li>
 <li>
 Required - Education to meet certification, license or registration requirement.
 </li>
 <li>
 Required - 2 years Clinical Experience as a Registered Nurse
 </li>
 <li>
 Required - 1 year Home Health Clinical Experience as an RN.
 </li>
 <li>
 Required - 1 year demonstrated proficiency in Home Health OASIS Review including all types of OASIS.
 </li>
 <li>
 Required - 1 year Experience with an Electronic Medical Record (EMR) system.
 </li>
 <li>
 Preferred - OASIS Certification.
 </li>
 <li>
 Preferred &ndash; Experience using Homecare Homebase (HCHB) EMR.
 
 
 </li>
 </ul>
 
 Certifications, Licenses, and Registrations
 
 
 
 <ul>
 <li>
 Required &ndash; Must be a licensed Registered Nurse in state of California.
 
 
 </li>
 </ul>
 Compensation range: $80,000 - $90,000
 
 
 
 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
 
 
 
 Compassus offers a comprehensive benefits package including, Medical, Dental, Vision, 401k and much more.
 
 
 At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
 
 
 
 Build a Rewarding Career with Compassus
 
 
 
 At Compassus, we care for our team members as much as we care for our patients and their families. Through our Care for Who I Am culture, we show compassion, respect, and appreciation for every individual. Embark on a career that cares for you while you care for others.
 
 
 
 Your Career Journey Matters
 
 
 
 We&rsquo;re dedicated to helping you grow and succeed. Whether you&rsquo;re pursuing leadership roles, specialized training, or exploring new career paths, we provide the tools and support you need to thrive.
 
 
 
 The Compassus Advantage
 
 
 
 <ul>
 <li>
 Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
 </li>
 <li>
 Career Development: Access leadership pathways, mentorship, and personalized professional development.
 </li>
 <li>
 Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
 </li>
 <li>
 Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being.
 </li>
 <li>
 Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
 </li>
 <li>
 A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.
 
 
 </li>
 </ul>
 
 Ready to Join?
 
 
 
 At Compassus, your career is more than a job&mdash;it&rsquo;s an opportunity to make a lasting impact. Take the next step and join a team that empowers you to grow, innovate, and thrive.
 
 
</div>

Clinical Documentation Specialist RN

Preventive Measures

<div>Summary: The Clinical Documentation &amp; Claims Compliance Specialist is responsible for reviewing clinical documentation and billing data to ensure services meet payer requirements and organizational compliance standards. This role supports the Billing Department by verifying authorizations, documentation accuracy, and claim readiness prior to submission. The specialist conducts quality assurance reviews to identify documentation deficiencies, authorization issues, and billing errors that may result in claim denials. This position works collaboratively with clinical staff, billing teams, and leadership to ensure accurate claim submission, minimize denials, and maintain compliance with Medicaid and payer regulations, including DC Medicaid billing requirements. 
Role: Lead, Manage, Accountability (LMA) 
Primary Job Responsibilities:<ul><li>Verify documentation supports billed CPT codes and services rendered.</li><li>Review clinical documentation to ensure services meet payer billing requirements.</li><li>Identify incomplete, late, or non-compliant documentation prior to billing.</li><li>Perform quality assurance reviews of claims to ensure accuracy prior to submission.</li><li>Confirm correct CPT codes, modifiers, diagnosis codes, and rendering provider information.</li><li>Verify authorization numbers and service approvals in payer portals prior to billing.</li><li>Ensure services billed align with approved authorizations and service limits.</li><li>Analyze denied claims to identify root causes related to documentation or billing errors.</li><li>Monitor denial trends and recommend corrective actions.</li><li>Maintain tracking logs for documentation reviews, authorizations, and claim errors.</li><li>Prepare weekly or monthly reports summarizing QA findings and trends.</li><li>Assist with internal compliance reviews and audit preparation.</li><li>Provide feedback to clinical staff on documentation requirements and compliance standards.</li></ul> 
Job Skills:<ul><li>Understanding of CPT, ICD-10, and healthcare billing practices.</li><li>Knowledge of Medicaid billing requirements and payer compliance rules.</li><li>Strong attention to detail and analytical skills.</li><li>Proficiency in Excel for tracking and reporting.</li><li>Ability to work independently while collaborating with clinical and billing teams.</li></ul> 
Education/Experience:<ul><li>Associate&rsquo;s or Bachelor&rsquo;s degree in healthcare administration, Health Information
</li><li>Management, Business Administration, or a related field preferred.</li><li>Experience</li><li>2+ years of experience in healthcare billing, clinical documentation review, or revenue</li><li>cycle operations.</li><li>Experience with Medicaid billing and authorization processes preferred.</li><li>Experience working with electronic health record (EHR) systems.</li></ul> 
Core Values:<ul><li>Do the Right Thing - We approach decisions with integrity, honesty, and transparency.</li><li>Own It - We take full responsibility for our role, commitments, and performance.</li><li>Serve First - We show up with a mindset of service to colleagues, clients, and the mission.</li><li>Choose Solutions - We display a solution-oriented mindset and bring constructive energy to</li></ul>
 challenges.<ul><li>Lead with Respect - We treat everyone with respect, communicate professionally, and handle</li></ul>
 conflict maturely.<ul><li>Commit to the Goal - We demonstrate focus, follow-through, and accountability to team</li></ul>
 objectives.</div>

Clinical Documentation & Claims Compliance Specialist

US Tech Solutions

<div>
 
 
 Duration:
 
 3 contracts
 
 
 
 Job Overview
 
 
 supports primary care providers by handling real-time clinical documentation, enabling providers to focus on delivering high-quality patient care. This role involves working closely with providers throughout the patient visit process&mdash;from pre-visit planning to post-visit documentation and follow-ups.
 
 In addition to traditional scribing responsibilities, this position plays a key role in improving clinical documentation accuracy, supporting value-based care initiatives, and assisting in identifying and closing care gaps.
 
 
 
 Key Responsibilities:
 
 
 1. Documenting Patient Encounters (:80%)
 <ul>
 <li>
 Accompany providers during patient visits to observe and document encounters in real time
 </li>
 <li>
 Record detailed clinical notes including history of present illness (HPI), physical exam, assessment, and plan
 </li>
 <li>
 Assign appropriate CPT and ICD-10 codes
 </li>
 <li>
 Prepare After Visit Summaries (AVS)
 </li>
 <li>
 Collaborate with providers to ensure accurate and complete documentation
 </li>
 </ul>
 2. Clinical Documentation Improvement (:10%)
 <ul>
 <li>
 Request and review patient medical records
 </li>
 <li>
 Utilize population health tools to enhance documentation quality
 </li>
 <li>
 Support daily huddles and clinical documentation reviews
 </li>
 <li>
 Identify opportunities to improve clinical documentation
 </li>
 </ul>
 
 3. Administrative Support (:10%)
 
 <ul>
 <li>
 Assist with orders, referrals, and task management
 </li>
 <li>
 Support providers and care teams with documentation-related activities
 </li>
 <li>
 Perform additional administrative duties as needed
 </li>
 </ul>
 
 
 Required Qualifications:
 
 
 
 Knowledge:
 
 <ul>
 <li>
 Understanding of medical terminology and common medications (through education or clinical experience)
 </li>
 <li>
 Exposure to clinical settings (shadowing, internships, or volunteering preferred)
 </li>
 <li>
 Prior scribe or transcription experience is a plus
 </li>
 </ul>
 
 Skills:
 
 <ul>
 <li>
 Strong listening and communication abilities
 </li>
 <li>
 High level of computer proficiency and ability to learn new systems quickly
 </li>
 <li>
 Multilingual skills are a plus (based on role requirements)
 </li>
 </ul>
 
 Abilities:
 
 <ul>
 <li>
 Ability to adapt quickly to new workflows and clinical environments
 </li>
 <li>
 Typing speed of 70+ WPM preferred (include typing speed on resume)
 </li>
 <li>
 Strong attention to detail and ability to follow provider direction
 </li>
 <li>
 Ability to work independently and as part of a care team
 </li>
 <li>
 Reliable attendance and professionalism in an in-person setting
 </li>
 <li>
 Commitment to at least 1 year in the role (2+ years preferred)
 </li>
 <li>
 Ability to work full-time (40&ndash;45 hours/week) during clinic hours
 </li>
 <li>
 Compliance with healthcare regulations, including HIPAA
 </li>
 </ul>
 
 
 About US Tech Solutions:
 
 
 US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com .
 
 
 US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
 
</div>

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