clinical documentation specialist

Adeptmed Healthcare Solutions

<p><b>Location:</b> Gurugram, Haryana<br/><b>Company:</b> AdeptMed Healthcare Solutions LLP<br/><b>Shift:</b> Night Shift (US Healthcare Process)<br/><b>Experience:</b> 4 &ndash; 9 years<br/><b>Working Days:</b> Monday to Friday</p><p><b>About the Role:</b></p><p>AdeptMed Healthcare Solutions LLP is hiring experienced <b>Nurse Auditors / Clinical Documentation Specialists</b> to join our growing US Healthcare team.<br/>You&rsquo;ll be responsible for reviewing clinical documentation, auditing medical records, and ensuring compliance with US healthcare standards.</p><p><b>Key Responsibilities:</b></p><ul><li>Review and audit clinical documentation in <b>EHR systems</b> for accuracy and completeness.</li><li>Identify and correct discrepancies in nursing notes, care plans, and assessments.</li><li>Ensure compliance with <b>MDS / PDPM</b> and other regulatory requirements.</li><li>Work closely with MDS coordinators, physicians, and facility staff to resolve documentation issues.</li><li>Prepare audit reports and recommend corrective actions.</li><li>Stay updated with <b>CMS</b> and <b>SNF compliance</b> guidelines.</li></ul><p><b>Qualifications:</b></p><ul><li><b>B.Sc. / M.Sc. Nursing</b> (AIIMS or equivalent preferred).</li><li><b>Registered Nurse (RN)</b> &ndash; India or International License (preferred).</li><li>4&ndash;9 years of experience in hospital, clinical, or documentation roles.</li><li>Prior experience in <b>clinical review / medical audit / DRG validation</b> preferred.</li><li>Excellent communication, analytical, and computer skills (MS Office, EHR).</li></ul><p><b>Perks &amp; Benefits:</b></p><ul><li>Competitive salary based on experience.</li><li>5-day working week (Saturday&ndash;Sunday off).</li><li>Growth opportunities in the <b>US Healthcare audit domain</b>.</li><li>Supportive and collaborative work environment.</li></ul><p>You can share your resume at Info@adeptmed.in or share your resume at 9220511288 ( onlywhatsapp )</p><p>Job Type: Full-time</p><p>Pay: &#8377;500,000.00 - &#8377;1,000,000.00 per year</p><p>Benefits:</p><ul><li>Flexible schedule</li><li>Health insurance</li><li>Leave encashment</li></ul><p>Work Location: In person</p>

Nurse Auditor / Clinical Documentation Specialist (Night Shift)

Vital Care Infusion Services, LLC

<div><div><b>Recognized as a &ldquo;Best Place to Work Modern Healthcare&rdquo; &ndash; Join a team where people come first.</b> At Vital Care, we are committed to creating an inclusive, growth-focused environment where every voice matters.</div>
<div></div><div>Vital Care (www.vitalcare.com) is the premier pharmacy franchise business with franchises serving a wide range of patients, including those with chronic and acute conditions. Since 1986, our passion has been improving the lives of patients and healthcare professionals through locally-owned franchise locations across the United States. We have over 100 franchised Infusion pharmacies and clinics in 35 states, focusing on the underserved and secondary markets. We know infusion services, and we guide owners along the path of launch, growth, and successful business operations.</div>
<div></div><div>What we offer:</div>
<ul><li>Comprehensive medical, dental, and vision plans, plus flexible spending, and health savings accounts.</li>
<li>Paid time off, personal days, and company-paid holidays.</li>
<li>Paid Paternal Leave.</li>
<li>Volunteerism Days off.</li>
<li>Income protection programs include company-sponsored basic life insurance and long-term disability insurance, as well as employee-paid voluntary life, accident, critical illness, and short-term disability insurance.</li>
<li>401(k) matching and tuition reimbursement.</li>
<li>Employee assistance programs include mental health, financial and legal.</li>
<li>Rewards programs offered by our medical carrier.</li>
<li>Professional development and growth opportunities.</li>
<li>Employee Referral Program.
</li></ul><div></div><div><b><i>Job Summary:</i></b></div>
<div>The role of the Medical Records Specialist is to review and respond to insurance correspondences and provide medical documentation to support accurate reflection of a patient&rsquo;s clinical status. Perform functions to safeguard and protect the patient's right to privacy by ensuring that only authorized individuals have access to the patient's medical information and that all releases of information comply with the request, authorization, company policy, and HIPAA regulations.</div>
<div></div><div><b><i>Duties/Responsibilities:</i></b></div>
<div><ul><li>Timely produce and deliver medical records in response to third-party payer requests, communicate with franchise partners, and outline needs of any missing documentation to satisfy requests.</li>
<li>Responsible for processing all release of information requests in a timely and efficient manner, ensuring accuracy, and providing customers with the highest quality product and customer service.</li>
<li>Validate requests and authorizations for releasing medical information according to established procedures.</li>
<li>Apply knowledge of medical terminology and clinical expertise to evaluate clinical documents.</li>
<li>Serve as a resource and communicate with franchises and other team members to facilitate or obtain comprehensive medical record documentation to reflect treatment.</li>
<li>Perform quality checks on all work to ensure the accuracy of the release and confidentiality.</li>
<li>Researches, analyzes, recommends, and facilitates a plan of action to correct discrepancies and prevent future documentation discrepancies.</li>
<li>Provide excellent customer service by being attentive and respectful; ensure understanding of customer requests and follow-through as promised; and proactively identify client concerns or problems.</li>
<li>May receive incoming requests, including opening mail, telephone inquiries, and retrieving facsimile inquiries, depending on the needs of the business.</li>
<li>Maintain working knowledge of the existing state laws.</li>
<li>Works independently to meet or exceed productivity and accuracy goals.</li>
<li>Carry out responsibilities of all Vital Care policies and procedures, including HIPAA and state/federal regulations.</li>
<li>Maintain confidentiality, security, and standards of ethics with all information.</li>
<li>Document actions taken within the systems in accordance with Vital Care processes.</li>
<li>Perform other related duties as assigned.</li>
</ul>
</div><div></div><div><b><i>Required Skills/Abilities:</i></b></div>
<div><ul><li>Excellent communication skills: listening, speaking, understanding, and writing English to advance reimbursement and collection efforts.</li>
<li>Strong organizational skills with the ability to track and maintain clear, complete records of activities, cases, and related documentation.</li>
 <li>Proven knowledge and skill in utilizing the MS Office suite of software and pharmacy applications.</li>
<li>Advanced data entry skills.</li>
</ul>
<div></div><div>Preferred Skills/Abilities:</div>
<ul><li>Understanding anatomy and physiology, disease process, medical terminology, and pharmacology.</li>
<li>Proficiency in reading and interpreting medical records, clinical documentation, and insurance correspondence.</li>
<li>Demonstrates ability to research clinical criteria, evaluate them for accuracy and quality, and ensure they meet accepted standards.</li>
<li>Demonstrate ability to appropriately apply clinical criteria to various claims and effectively utilize audit tools.</li>
<li>Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.</li>
</ul>
<div></div><div><b><i>Education and Experience:</i></b></div>
<div><ul><li>High school diploma or equivalent and additional specialized training (Required).</li>
<li>Healthcare experience: +2 years (Preferred).</li>
<li>Licensed practical nurse (Preferred).</li>
<li>Clinical experience and knowledge of complex diseases (Preferred).</li>
<li>Experience in reviewing and interpreting medical records (Preferred).</li>
</ul>
<div></div><div><b><i>Physical Requirements:</i></b></div>
<div><ul><li>Sitting: Prolonged periods of sitting are typical, often for the majority of the workday.</li>
<li>Keyboarding: Frequent use of a keyboard for typing and data entry.</li>
<li>Reaching: Occasionally reaching for items such as files, documents, or office supplies.</li>
<li>Fine Motor Skills: Precise movements of the fingers and hands for tasks like typing, using a mouse, and handling paperwork.</li>
<li>Visual Acuity: Good vision for reading documents, computer screens, and other detailed work.</li>
</ul>
<div></div><div><div>Be part of an organization that invests in you! We are reviewing applications for this role and will contact qualified candidates for interviews.<br>
<br>
Vital Care Infusion Services is an equal-opportunity employer and values diversity at our company. We do not discriminate on the basis of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans&rsquo; status, or any other basis protected by applicable federal, state, or local law.<br>
<br>
Vital Care Infusion Services participates in E-Verify.</div>
<div></div><div>This position is full-time.</div></div></div></div></div></div>

Medical Records Specialist

Central Maine Healthcare

<div>Overview:
<div><b>
Central Maine Healthcare</b> is seeking a <b>Full Time</b>,<b> Clinical Documentation Improvement Manager</b> to join our team!</div><div></div><div><br>
Central Maine Healthcare is an integrated healthcare delivery system serving 400,000 people living in central, western and Midcoast Maine. CMH's hospital facilities include Central Maine Medical Center in Lewiston, Bridgton Hospital and Rumford Hospital. CMH also supports Central Maine Medical Group, a primary and specialty care practice organization. Other system services include the Central Maine Heart and Vascular Institute, a regional trauma program, LifeFlight of Maine's southern Maine base, the Central Maine Comprehensive Cancer Center and other high-quality clinical services.</div><div></div><div><br>
If you are passionate about making a difference and are looking for your next great career opportunity, we look forward to reviewing your application!</div><br>
<div></div>
Responsibilities:
<div>
Manages the CDI program and day to day CDI operations related to the concurrent review of the clinical documentation in the medical record. Collaborates with Senior Director HIM, providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient. Utilizes clinical expertise and clinical documentation improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy, standards, goals and core values of Central Maine Healthcare.</div><div></div><div><br>
Actively participates in planning, administering and evaluating the operations of the Clinical Documentation Improvement Team. Assists in the development of long and short-term goals for the department, promoting quality care and optimal patient outcomes in a fiscally responsible manner. Effectively maintains
<br>
communication with employees, and physicians.</div>
Qualifications:
<ul><li>5+ years acute care hospital clinical RN experience</li><li>
3+ years of experience in Clinical Documentation Improvement</li><li>
Current Licensure from the Maine State Board of Nursing</li><li>
CCDS, CDIP or CCS certification preferred</li><li>
BSN degree or equivalent preferred</li></ul>
Employment Status: Full Time Shift: Days Equal Employment Opportunity:
<div>
CMH actively promotes diversity in its workforce at all levels of the organization. We strive to create and maintain a setting where we celebrate cultural and other differences and consider them strengths of the organization. CMH is an equal opportunity workforce and no one shall discriminate against any individual with regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, genetic information or veteran status with respect to any offer, or term or condition, of employment. We make reasonable accommodations to the known physical and mental limitations of qualified individuals with disabilities.</div></div><div></div>

Clinical Documentation Improvement (CDI) Manager

Christus Health

<strong>Description</strong><br><p><b><u>Summary:</u></b></p><p>This position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The clinical documentation RN will provide support and expertise through comprehensive assessment and review of inpatient medical records. The clinical documentation RN will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.</p><p><b><u>Responsibilities:</u></b></p><ul><li>Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation</li><li>Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation</li><li>Maintains positive open communication with physicians, nursing and all other disciplines involved in the care of the patient</li><li>Works closely with HIM Coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care</li><li>Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures</li><li>Updates DRG worksheet to reflect any changes inpatient status/procedure/treatment and confers with the physician to finalize diagnosis</li><li>Consistently meets established productivity targets for record review</li><li>Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation</li><li>Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies</li><li>Assists in collection and organization of data for analysis by appropriate medical and hospital committees</li><li>Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation</li><li>Demonstrates competence to perform assigned responsibilities is a manner that meets the population-specific and developmental needs of the members served by the department</li><li>Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served</li><li>Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities</li><li>Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties</li><li>Performs other duties as assigned</li></ul><p><b><u>Requirements:</u></b></p><ul><li>Associate's Degree in Nursing</li><li>RN License in state of employment or compact</li></ul><p><u>Work Schedule:</u><br></p><p>8AM - 5PM Monday-Friday</p><p><b><u>Work Type: </u></b></p><p>Full Time</p><p><br></p><img src="https://www.jobg8.com/Tracking.aspx?JsLKHhWaKsPVWP%2bZ6BKZ1SuJ5KwC0619p" width="0" height="0" />

Clinical Documentation Registered Nurse II - Document Integrity

University Health

<div><p><b>Exciting Opportunity: Charge Review Analyst at University Health in San Antonio!</b></p>
<p>
Are you ready to make an impact in healthcare and be part of a nationally recognized, top-tier health system? University Health in San Antonio, Texas, is seeking a dynamic <b>Charge Review Analyst</b> to join our outstanding team. This position offers an exciting chance to work at one of the most innovative and award-winning hospitals in the region.</p>
<p><b>
Why University Health?</b></p>
<ul>
<li><b>Top 10% in the Nation</b> for clinical excellence, recognized by U.S. News &amp; World Report.</li>
<li><b>Magnet&reg; Recognized Hospital</b> &ndash; the highest national honor for nursing excellence.</li>
<li><b>A Leader in Patient Care</b> &ndash; providing exceptional healthcare to our community with compassionate service.</li>
<li><b>Top-Tier Benefits</b> &ndash; comprehensive health plans, generous paid time off, tuition reimbursement, and more!</li>
<li><b>Cutting-Edge Technology</b> &ndash; work with the Epic EHR system and collaborate with experts across clinical, IT, and financial departments.</li>
<li><b>A Culture of Collaboration</b> &ndash; join a team committed to high-quality service and patient care.</li>
</ul>
<p><b>What You&rsquo;ll Do:</b></p>
<p>
As a <b>Charge Review Analyst</b>, you'll be the crucial link between clinical, financial, and IT teams. Your expertise will help maintain the highest standards for charge capture across all clinical services, ensuring accurate and timely charge entry. You&rsquo;ll provide invaluable support to various clinical departments, leading training, identifying issues, and delivering actionable solutions.</p>
<p>
Key Responsibilities:</p>
<ul>
<li>Oversee charge capture practices for multiple clinical departments.</li>
<li>Serve as the primary point of contact for clinical leaders, IT, coding, billing, and compliance teams.</li>
<li>Perform root cause analysis and system updates to ensure accurate clinical charge entry.</li>
<li>Deliver exceptional service to clinical teams, nursing staff, and revenue cycle colleagues.</li>
<li>Schedule and lead meetings to resolve charge-related concerns, enhancing departmental processes.</li>
<li>Collaborate in workflow reviews and provide ongoing education and support.</li>
<li>Utilize your expertise in Epic and other hospital information systems to ensure smooth operations.</li>
</ul>
<p><b>What You&rsquo;ll Bring:</b></p>
<ul>
<li>Bachelor&rsquo;s degree in Accounting, Finance, Healthcare, or a related field (or equivalent clinical experience).</li>
<li>Minimum of 2 years of experience in revenue integrity, charge capture, or clinical documentation improvement.</li>
<li>Proficiency in Epic EHR system and other related applications (Excel, MS Office Suite).</li>
<li>Knowledge of medical terminology, coding, and payer reimbursement methodologies (Commercial and Government).</li>
<li>Strong communication, technical, and critical thinking skills.</li>
</ul>
<p><b>Preferred Qualifications:</b></p>
<ul>
<li>Epic Certification in HB Resolute.</li>
<li>Experience in Medicare and other payer reimbursement processes.</li>
<li>Experience in a revenue integrity program and working with clinical documentation systems.</li>
</ul>
<p><b>Why Join Us?</b> At University Health, you&rsquo;ll be part of an organization that is <b>dedicated to excellence</b>, <b>innovation</b>, and <b>collaboration</b>. We believe in empowering our employees to succeed and grow&mdash;whether that&rsquo;s advancing your career or enhancing your professional skills. Working at University Health means making a real difference in the lives of our patients and community.</p>
<p>
Ready to take the next step in your career? <b>Apply today</b> and become part of the University Health family, where exceptional care and a supportive team environment are at the heart of everything we do!</p>
<p><b>
University Health &ndash; Excellence in Patient Care, Excellence in Your Career.</b></p></div>

Charge Review Analyst

DIABCARE INDIA

<p><b>Patient Care</b></p><p><b>Care Coordination</b></p><p><b>Patient Education and Support</b></p><p><b>Clinical Documentation</b></p><p><b>Professional Development</b></p><p><b>Quality Improvement</b></p><p><b>Safety and Compliance</b></p><p>Job Types: Full-time, Permanent, Fresher</p><p>Pay: &#8377;7,000.00 - &#8377;15,000.00 per month</p><p>Work Location: In person</p>

Staff Nurse

Orlando Health

<div>Position Summary:<div></div><div><b><br>
Department:</b> Health Information Management</div><div><b>
Status:</b> Full-Time</div><div><b>
Shift:</b> Monday - Friday, 8am-4:30pm</div><div><b>
Fully On site</b> <b>at Dr. Phillips Hospital</b></div><div></div><div><br>
At Orlando Health, we are ordinary people with extraordinary individuality, working together to bring help, healing and hope to those we serve. By daily embodying our over 100-year legacy, we reinforce our reputation as a trusted and respected healthcare organization that delivers professional and compassionate care to our patients, families and communities. Through our award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities, our 27,000+ team members serve communities that span Florida&rsquo;s east to west coasts and beyond.</div><div></div><div><b><br>
ORLANDO HEALTH - BENEFITS &amp; PERKS:</b></div><div><b>
All Inclusive Benefits (start day one)</b></div><ul><li>
Student loan repayment, tuition reimbursement, FREE college education programs, retirement savings, paid paternity leave, fertility benefits, back up elder and childcare, pet insurance, PTO/Holidays, and more for full time and part time employees.</li></ul><div><b>
Forbes Recognizes Orlando Health as a Best-In-State Employer</b></div><ul><li>
Forbes has named Orlando Health as one of America's Best-In-State Employers for 2024. Orlando Health is the top healthcare organization in the Metro Orlando area to make the prestigious list. <i>&quot;We are proud to be named once again as a best place to work,&quot;</i> said Karen Frenier, VP (HR). &quot;This achievement reflects our positive culture and efforts to ensure that all team members feel respected, supported and valued.</li></ul><div><b>
Employee-centric</b></div><ul><li>
Orlando Health has been selected as one of the &ldquo;Best Places to Work in Healthcare&rdquo; by Modern Healthcare</li></ul><div></div><div><b><br>
Position Overview:</b></div><div>
The HIM Deficiency Analyst II responsibilities include performing duties related for the deficiency tracking to management the overall deficiency workflow process of health information in the electronic medical record. Also reviews the clinical documentation to identify missing deficiencies and clinical documentation. The Analyst II assists with the training and education of the Analyst I to ensure proficiency with the record completion is accurately completed.
</div>Responsibilities:
<div><b>
Essential Functions
</b><br>
<ul><li>Retrieves, processes and ensure all discharge records from all patient care areas when applicable.
</li><li>Initiates and performs technical procedure to analyze, or reanalyze, and monitor for medical record deficiencies according to Joint Commission and Medical Staff Rules and Regulations for regulatory requirements.
</li><li>Perform daily deficiency analysis in the comprehensive health record to ensure chart completion.
</li><li>Assist with the reanalyzes and loose sheets imaged separately from the discharged medical record.
</li><li>Gathers statistical data regarding individual physicians&rsquo; record documentation and completion procedures for reporting to the Medical Records Committee and any other hospital committee as needed.
</li><li>Assists medical staff members in all aspects of record completion.
</li><li>Understands and performs the corporate suspension procedures in the absence of the Analyst III.
</li><li>Assumes a leadership role for the training and education of the Analyst I in the Record Access and Birth Registry areas.
</li><li>Assist with training new members on HIM systems to ensure compliance and timely analysis of the clinical documentation.
</li><li>Maintain proficiency with the deficiency analysis queued to by demonstrating efficiency with managing the workflow.
</li><li>Assist the HIM Analyst III with quality audits as requested.
</li><li>Knowledge on the suspension process to assist the other HIM Analysts as needed.
</li><li>Communicates cooperatively and constructively with physicians, patients, guests, and members of the healthcare team.
</li><li>Ensures the workflow of all processes within their areas.
</li><li>Meets productivity, timeliness, and quality standards, and goals set by the department. Provides data for monitoring productivity and outcomes through maintenance of spreadsheets, database, and/or other documentation process.
</li><li>Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
</li><li>Maintains compliance with all Orlando Health policies and procedures.</li></ul></div><div><br>
</div><div><b>Other Related Functions
</b><br>
<ul><li>Works independently.
</li><li>Demonstrates exemplary customer services skills.
</li><li>Displays leadership skills to include critical thinking and issues resolution.
</li><li>Utilizes process/performance improvement skills.
</li><li>Assumes responsibility for professional growth and development.
</li><li>Train new team members.
</li><li>For telecommuting positions, able to work independently and troubleshoot hardware/software items.
</li></ul></div>Qualifications:
<div><b>
Education/Training
</b></div><ul><li>High school diploma or equivalent education.
</li><li>Computer literacy and keyboarding skills required.
</li><li>Must type a minimum of 30 words per minute.
</li><li>Successfully passes a Windows proficiency test, scoring 80% or higher prior to an interview.
</li><li>Medical terminology required.</li></ul><div><br>
</div><div><b>Licensure/Certification
</b><br>
None.</div><div><b><br>
Experience
</b><br>
<ul><li>Three (3) years of progressive experience in the Health Information Management field.
</li><li>Completion of an approved HIM or HIT program may substitute for up to one (1) year of the required experience.
</li><li>Experience with chart completion and deficiency analysis.</li></ul></div></div>

HIM Deficiency Analyst II

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