documentation specialist

PSA BDP

<div>
 <strong>
  Job Description
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Ensure that all documentation is completed neatly, professionally, accurately and error-free with all current information in proper order and within corporate standards for timelines.
  </li>
  <li>
   Close all files within four working days from action date ensuring compliance to all customer requirements, consignee letter of transmittal standard instructions, letter of credit requirements and/or order specific instructions.
  </li>
  <li>
   Complete final inspection for accuracy of all bills of lading received for closing.
  </li>
  <li>
   Ensure that documents are distributed to all necessary parties within four working days from action date.
  </li>
  <li>
   Ensure billings of all closed shipments are billed within four workdays from action.
  </li>
  <li>
   Prepare and double-check BDP invoices, ensuring that all charges are correct.
  </li>
  <li>
   Participate in cross training and learn the processes of other members of the facility so that you are able to cover their responsibilities in case of illness, vacation or during times of peak workload.
  </li>
  <li>
   Ensure you understand and adhere to all customer requirements and operating standards.
  </li>
  <li>
   Document, maintain and update work processes/procedures as they relate to each customer account.
  </li>
  <li>
   Notify team coordinator if needed information is not being provided in time.
  </li>
  <li>
   Regular communication with operations and RSC/GSC personnel on obstacles preventing timely bill and close.
  </li>
  <li>
   Air / Ocean / Truck
   <br/>
   <br/>
  </li>
 </ul>
 Job Requirements
 <br/>
 <br/>
 ∙ +3 years of detailed experience of logistics and forwarding operations/regulations and documentation
 <br/>
 <br/>
 ∙ Preferable a professional degree by a licensed educational institution specialized in logistics and forwarding.
 <br/>
 <br/>
 ∙ Computer literacy with Microsoft Software applications and /or other market leading software applications.
</div>


Documentation Specialist

Banner Health

<div><p><b>Department Name:
</b></p>Clin Document Integrity-Corp<p></p><p><b>
Work Shift:
</b></p>Day<p></p><p><b>
Job Category:</b></p>
Revenue Cycle<p></p><p>
Explore and excel. At Banner Health, health care is a team effort. One might be surprised by the number of people who work behind the scenes and play a critical role in ensuring the best care for our patients.</p><p></p><p>
The mission of the <b>Clinical Documentation Improvement Department</b> is to, &ldquo;Facilitate concise clinical documentation to appropriately reflect patient acuity, risk of mortality, and resource utilization in order to properly reflect patient care given and optimize organizational goals.&rdquo; This mission also supports the accurate translation of diagnoses into ICD-10 codes for patient billing and capture of quality metrics.</p><p></p><p><b>
As a successful Clinical Documentation Improvement Specialist will need to have at a minimum 2-4 years of hospital acute-care or relevant clinical experience. Time in OR, ED or ICU may strengthen a candidates profile. Level of education may be either registered nurse with active licensure in state worked or graduate of foreign medical school with Doctor of medicine degree.
</b></p><p></p><p><b>This is a fully remote position and available if you live in the following states only: AK, AL, 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.
</b></p><p></p><p>This position is fully remote with travel less than 15% of the time to either a Banner corporate or hospital site. With this remote work, candidates must be self-motivated, possess moderate to strong tech skills and be able to meet daily and weekly productivity metrics. <b>You are required to work at least 75% of your shift within 7AM to 7PM AZT/MST. No holidays or weekends.</b> Business hours are Monday-Friday, 8 hour shifts with no weekends or holidays.
</p><p></p><p>Your pay and benefits (Total Rewards) are important components of your Journey at Banner Health. Banner Health offers a variety of benefit plans to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life.<b> Apply today!
</b></p><p></p>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.<p></p><p>
POSITION SUMMARY<br>
This position is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position is a member of the clinical team responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the diagnostic related group (DRG), severity of illness (SOI), risk of mortality (ROM), risk adjustment, and the complexity of patient care rendered. This position is responsible for reviewing content of the medical record and assisting in the clarification of documentation ambiguities.<br>
<br>
CORE FUNCTIONS<br>
1. Provides subject matter expertise related to DRG, clinical documentation opportunities and requirements. Serves as an essential member of the clinical team, emphasizing their role in reviewing content of the medical record, assisting in the clarification of documentation ambiguities. Serves as the liaison between acute care coding and providers in order to capture accurate DRG, SOI, ROM, risk adjustment, reimbursement, and complexity of patient care rendered.</p><p></p><p>
2. Conducts accurate and timely concurrent record reviews, recognizing opportunities for documentation improvement through specialized training and software. Utilizes available resources to formulate clinically credible and compliant provider documentation clarification (queries ) aimed at improving the accuracy of the documentation process.<br>
<br>
3. Ensures data integrity of the clinical documentation database through compliant, accurate and appropriate entries, which includes but is not limited to, accurate input of case data, correct assignment of documentation clarification types and provider responses, and ensuring precise case reconciliation with correct DRG shifts recorded.<br>
<br>
4. Ensures the accuracy and completeness of clinical information used for measuring and reporting provider and facility outcomes (e.g., DRG assignment, hospital acquired conditions, patient safety indicators, quality of care, facility and system initiatives) while maintaining compliance with HIMS dept time requirements for coding and billing revenue cycle.<br>
<br>
5. Educates customers through presentations and/or reports for clinicians and facility management on clinical documentation opportunities, acute care coding and reimbursement issues, as well as performance improvement methodologies.<br>
<br>
6. This position works independently in a remote work model and has multi-facility/entity responsibility, with no direct budgetary oversight. This position requires extensive interaction with providers, HIMS professionals, nursing, and other ancillary staff.<br>
<br>
MINIMUM QUALIFICATIONS</p><p></p><p>
Requires Registered Nurse (RN) license in state of residence.</p><p>
Must possess a strong knowledge of clinical care as normally obtained through the completion of a bachelor&rsquo;s degree in nursing.<br>
<br>
Requires two years of acute clinical care experience.</p><p></p><p>
Must have the ability to interface with multiple software applications, work independently, possess demonstrated critical thinking skills, problem-solving abilities, communication and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format.<br>
<br>
PREFERRED QUALIFICATIONS</p><p><br>
Experience with acute clinical documentation programs or coding. Certified Clinical Documentation Specialist, (CCDS), Certified Documentation Integrity Practitioner (CDIP), Certified Coding (CCS) Specialist credential., or Certified Professional Coder (CPC).<br>
<br>
Additional related education and/or experience preferred.</p><p></p><p><b>
Estimated Pay Range:</b></p>
$37.14 - $61.90 / 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.
<p><b>EEO Statement:</b></p><p>
EEO/Disabled/Veterans</p><p>
Our organization supports a drug-free work environment.</p><p></p><p><b>
Privacy Policy:</b></p><p>
Privacy Policy</p></div><p></p>

RN Clinical Documentation Specialist

SGS Consulting

<div>
 <p>
  <strong>
   Title: Technical Documentation Specialist / Writer
  </strong>
 </p>
 <p>
  <strong>
   Location: Research Triangle Park, NC 27709 (Onsite)
  </strong>
 </p>
 <p>
  <strong>
   Job Duration: 06 months Contract + (Highest possibilities of contract extension)
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    Description:
   </u>
  </strong>
 </p>
 <p>
  <strong>
   Location: Onsite, RTP Campus, NC
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    Job Description:
   </u>
  </strong>
 </p>
 <p>
  As a member of Manufacturing Sciences, the Technical Writer will provide written documentation expertise to the clinical and commercial manufacturing campaigns run at the Parenteral Facility RTP Pharma Site. The focus of this position will be as a key leader for investigations and project implementation for Manufacturing Sciences using their technical expertise on fill/finish, visual inspection, and packaging.
 </p>
 <p>
  The incumbent will be tasked with writing PPQ Protocols, PPQ Reports, data verification activities for confirmation of source data for reports, preliminary writing for sections of the filing. Creating the Master Sample Matrix (MSM) for Manufacturing personnel to be used for on the production floor activities.
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <u>
    Qualifications/Education:
   </u>
  </strong>
 </p>
 <ul>
  <li>
   Life Science background with at least 5 years experience is preferred.
  </li>
  <li>
   Good communication and project management skills appropriate for leadership of tech transfer projects.
  </li>
  <li>
   Working knowledge in technical understanding of Parenteral Filling Operations (e.g. Filling Isolator, Lyophilizer, Visual Inspection) including transfer of such processes into full-scale drug product manufacturing facilities.
  </li>
  <li>
   Excels at working in a team environment.
  </li>
  <li>
   Comfortable analyzing scientific datasets/analytical skills with excellent written skills.
  </li>
  <li>
   Ability to work independently and support a large cross-functional group.
  </li>
  <li>
   Some knowledge of cGMP, FDA/EMA regulations, Process Performance Qualification, Continued Process Verification.
  </li>
 </ul>
</div>


Technical Documentation Specialist / Writer

Johns Hopkins Medical Management Corporation

<b>Overview:</b><br>
Johns Hopkins Intrastaff is the internal staffing agency for the Johns Hopkins Health System and partner hospitals, providing temporary support to a variety of the Johns Hopkins locations. Our employees are the strength of our service. Intrastaff is unique because it's one of the very few agencies where a person has the benefit of being a temporary employee and also feels like a member of a large organization. Working at Hopkins means joining a culturally diverse team that includes some of the best nurses, physicians and allied health professionals in the world. Directly or indirectly, you'll have exposure to cutting-edge technology and groundbreaking medical research.
<br><br>
CD RN (Clinical Documentation Specialist)-Level 2
<br><br>
The Clinical Documentation Specialist (CDS) is responsible for distributing documentation
<br>information to respective departments; performing educational outreach to individual units and
<br>provider groups along with the CDS assigned to those units; supports training of new staff
<br>members; and the design and development of educational tools for staff and Providers. This role
<br>facilitates the improvement in the overall quality and completeness of concurrent medical
<br>record documentation to help achieve accurate inpatient coding, APR-DRG assignment, severity
<br>level and reimbursement. This role functions as subject matter liaison, leads and manages
<br>documentation improvement initiative, serves on internal hospital committees. CDS will obtain
<br>appropriate documentation through interactions with physicians and collaboration with other
<br>departments. Additional responsibilities as assigned
<br><br>
<b>Shift/hours:</b> Mon – Fri, 8:00am-5:00pm EST **Must work these hours/log on during this time frame - EST**
<br><b>Location:</b> 100% Remote (EST hours)
<br><br>
Payrate- $60 hourly
<br><br>
<b>Responsibilities:</b><br>
<b>Knowledge:</b><br>
Comprehensive knowledge of anatomy, physiology, as defined by the Medical Diagnostic Categories and all body systems.
<br>Strong background knowledge of disease processes and pharmacology.
<br>College-level knowledge of Medical Terminology.
<br>Complete and thorough understanding of the unique functions of each clinical area.
<br>Requires in-depth knowledge of clinical coding processing and documentation standards,guidelines, policies, and procedures.
<br>Must be conversant in clinical documentation improvement.
<br>High level of proficiency in adult education and training
<br><br>
Thorough understanding of Hospital bylaws and Joint Commission standards related to departmental activities.
<br>Clinical pertinence requirements and proficiency in abstraction and data entry into all the database systems used for clinical documentation.
<br>Must be able to read and interpret electronic and manual documentation generated by healthcare professionals.
<br>Requires understanding of HSCRC, Maryland Quality Improvement Programs and CMI impact on hospital budget
<br>Knowledge of Healthcare Insurance Portability and Accountability Act (HIPAA)
<br><br>
<b>Skills:</b><br>
<b>Must be conversant in:</b> ICD-10-CM, APRDRGs, DRGs
<br>Strong interpersonal, communication (verbal, non-verbal, and listening) skills.
<br>An understanding of adult learning theory, instructional design, and critical thinking
<br><b>Operating at competent level with, but not limited to:</b> Microsoft Office Suite, web-browsers,email, electronic health records, online collaboration software, virtual meeting applications
<br>Strong interpersonal skills and ability to effectively communicate with team members
<br>Ability to work in a dynamic, team-oriented environment
<br>Ability to work independently and be self-directed
<br>Ability to work under pressure to meet submission, project, and reporting deadlines
<br>Ability to work in a fast-paced academic teaching hospital
<br><br>
<b>Qualifications:</b><br>
<b>Education:</b><br>
<b>Requires successful completion of:</b><br>
Baccalaureate degree, or associates degree, or diploma in nursing from an accredited school of Nursing OR
<br>successful completion of an AMA approved Physician Assistant program, OR
<br>successful completion of the academic requirements of Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
<br><br>
<b>Required:</b><br>
Active RN License
<br><br>
EPIC experience
<br><br>
(12) months current RN experience in similar role in MD or nationally using MSDRG.
<br>Medicare Coding regulations 2024
<br><br>
Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting. Minimum of 2 years as a Clinical Documentation Specialist required. In lieu of complex acute care experience, a minimum of 3 years of CDI experience, and /or other relevant clinical experience may be considered.
<br><br>
Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

Clinical Documentation Specialist RN

DHR Health

<div><p>DHR Health - US:TX:McAllen - Days
</p><p>Summary:<br>
<br>
</p><p><b>MISSION STATEMENT:
</b></p><p>Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.
</p><p></p><p><b>VISION:
</b></p><p>Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.<br>
</p><p></p><p><b>POSITION SUMMARY:
</b></p><p>The Primary role of a medical &ldquo;Documentation Specialist&rdquo; is to assist the physician with the complete documentation of patients&rsquo; charts. Documentation Specialists accompany the physician as he/she examines and interviews patients and then records the physician&rsquo;s observations and comments on either on paper or in an electronic medical record (EMR) depending on what the practice uses. Documentation Specialist will accompany physician on all clinic consultations as required. All information is recorded in the presence of a physician, as dictated by the physician.<br>
</p><p></p><p><b>POSITION EDUCATION/QUALIFICATIONS </b><b>:
</b></p><ul><li>High School graduate or equivalency is preferred.
</li></ul><ul><li>Medical Terminology required.
</li></ul><ul><li>CNA or Medical Assistant certification from an accredited school preferred.
</li></ul><ul><li>Excellent customer service skills.
</li></ul><ul><li>Computer skills required with knowledge of Microsoft Office suite.
</li></ul><ul><li>Good written and verbal communication skills required.
</li></ul><ul><li>Bilingual &ndash; English/Spanish.
</li></ul><p></p><p><b>JOB KNOWLEDGE/EXPERIENCE </b><b>:
</b></p><ul><li>One ( <b>1 </b>) year experience in a hospital or physician office setting is preferred.
</li></ul><ul><li>Previous experience as a medical scribe preferred.
</li></ul><ul><li>Demonstrates proficiency in Microsoft Office applications.
</li></ul><ul><li>Previous experience with an EMR system preferred.
</li></ul><ul><li>Must have excellent customer service and organizational skills.
</li></ul><ul><li>Requires reasoning ability and good independent judgment.
</li></ul><p>Responsibilities:<br>
<br>
</p><p><b>POSITION RESPONSIBILITIES:
</b></p><ul><li>Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices
</li></ul><ul><li>Keep track of laboratory tests, medications, and radiology tests ordered by the physician
</li></ul><ul><li>Gather data for physician review (i.e., laboratory results, faxed radiology reports, medical records)
</li></ul><ul><li>Coordinate communication between physicians and staff, make and answer telephone calls
</li></ul><ul><li>Document any consultations the physician makes to a patient&rsquo;s personal doctor, family members, on-call physician, or other members of the medical community.
</li></ul><ul><li>Take vital signs and room patients as needed.
</li></ul><ul><li>Accompany physician on all clinic consultations as required.
</li></ul><ul><li>Provide patients with updates about waits and delays.
</li></ul><ul><li>Document all procedures done by the physician, as dictated by the physician.
</li></ul><ul><li>Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient.
</li></ul><ul><li>Other duties as assigned.<br>
</li></ul><p></p><p><b>LINES OF REPSONSIBILITY </b><b>:
</b></p><p>(Chain-of-command) 1.Clinic Manager 2. Director DHR Health Clinics 3. Chief Ambulatory Officer
</p><p>Other information:<br>
<br>
</p><p><b>CUSTOMER SERVICE:
</b></p><p>Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.<br>
</p><p></p><p><b>AGE SPECIFIC </b>:
</p><p>Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient&rsquo;s status and interpret the appropriate information needed to identify each patient&rsquo;s requirement relative to his or her age.
</p><p></p><p><b>AMERICANS WITH DISABILITIES ACT: (ADA) </b>:
</p><p></p><p>A. <b>Essential Duties </b>: Indicated by bold print within performance standards, preceding individual numbered criteria.
</p><p></p><p><b>The following table provides physical requirements that will be associated with, but not limited to, this position:
</b></p><p></p><div><div><div><div><p>Light/moderate lifting up to 20 lbs, from the floor to shoulder height.<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Kneeling<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Must be able to assist other employees with lifting more than 20 lbs.<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Walking<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Light/moderate carrying up to 20 lbs.<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Standing/Squatting<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Straight pulling<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Sitting<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Pulling hand over hand<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Pushing<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Repeated bending<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Stooping/Bending<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Reaching above shoulder<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Climbing Stairs<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Simple grasping<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Climbing Ladders<br>
</p></div><div><p>No<br>
</p></div></div><br>
<div><div><p>Dual simultaneous grasping<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Depth Perceptions needed<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Ability to see<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Identify Colors<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Operating office equipment<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Twisting<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Operating mechanical equipment<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Crawling<br>
</p></div><div><p>No<br>
</p></div></div><br>
<div><div><p>Ability to read and write<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Ability to Count<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Ability to hear verbal communication without aid<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Operating Personal Vehicle<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Ability to comprehend written/verbal communication<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Other: Ability to deal with stress<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>OSHA Category<br>
</p></div><div><p>III<br>
</p></div></div><br>
</div></div><p></p><p>B. <b>Working Conditions </b><b>: </b>The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.
</p><p></p><p>C. <b>Occupational Exposure: </b>This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.
</p><p></p><p>D. <b>Aptitudes </b><b>: HIGH 1 2 3 4 5 6 LOW
</b></p><p></p><p><b>Intelligence: </b>General learning ability: The ability to &ldquo;catch on&rdquo; or understand instructions and underlying principles. Ability to reason and make judgments. <b>3
</b></p><p></p><p><b>Verbal: </b>Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. <b>3
</b></p><p></p><p><b>Numerical: </b>Ability to perform arithmetic operations quickly and accurately. <b>2
</b></p><p></p><p><b>Spatial: </b>Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to &ldquo;visualize&rdquo; objects or two or three dimensions, or to think visually of geometric forms. <b>2
</b></p><p></p><p><b>Form Perception: </b>Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. <b>3
</b></p><p></p><p><b>Clerical Perception: </b>Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. <b>2
</b></p><p></p><p><b>Motor Coordination: </b>Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. <b>3
</b></p><p></p><p><b>Finger Dexterity: </b>Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. <b>3
</b></p><p></p><p><b>Manual Dexterity: </b>Ability to move hands easily and skillfully. To work with hands in placing and turning motions. <b>3
</b></p><p></p><p><b>Eye-Hand-Foot Coordination: </b>Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. <b>3
</b></p><p></p><p><b>Color Discrimination: </b>Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. <b>3
</b></p><p></p><p>I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.
</p><p></p><p>If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.
</p><p></p><p>Employee Signature: ________________________________ Date: ____________________
</p><p></p><p>Transfer/Hire Date Effective: ________________________.</p></div>

Documentation Specialist - FT - Days - Neurology (Dr. Simms)

UC Irvine Health

<div>Overview:
<div><b>
UCI Health</b> is the clinical enterprise of the University of California, Irvine, and the only academic health system based in Orange County. UCI Health is comprised of its main campus, UCI Medical Center, a 459-bed, acute care hospital in in Orange, Calif., four hospitals and affiliated physicians of the UCI Health Community Network in Orange and Los Angeles counties and ambulatory care centers across the region. Listed among America&rsquo;s Best Hospitals by U.S. News &amp; World Report for 23 consecutive years, UCI Medical Center provides tertiary and quaternary care and is home to Orange County&rsquo;s only National Cancer Institute-designated comprehensive cancer center, high-risk perinatal/neonatal program and American College of Surgeons-verified Level I adult and Level II pediatric trauma center, gold level 1 geriatric emergency department and regional burn center. UCI Health serves a region of nearly 4 million people in Orange County, western Riverside County and southeast Los Angeles County.</div><div>
To learn more about UCI Health, visit www.ucihealth.org.</div>
Responsibilities:
<div><b>
Position Summary:
</b></div><div>The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through comprehensive auditing and evaluation of the medical record. Proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement. Educates others on documentation guidelines on an ongoing basis. Collects and analyzes data to provide reports and make recommendations.</div>
Qualifications:
<div><b>
Required Qualifications:</b></div><ul><li>
Strong clinical knowledge with ability to interpret clinical documentation</li><li>
Must possess the skill, knowledge and ability essential to the successful performance of assigned duties</li><li>
Must demonstrate customer service skills appropriate to the job</li><li>
Must be available for occasional weekend coverage</li><li>
Knowledge of laws, rules and regulations regarding appropriate clinical documentation including coding guidelines and coding clinics</li><li>
Five (5) or more years of clinical experience as either an RN or Physician and 3 years&rsquo; experience in CDI</li><li>
Familiarity with Utilization Review criteria</li><li>
Familiarity of Joint Commission and CMS requirements</li><li>
Excellent written and verbal communication skills in English</li><li>
Critical thinking skills to problem solve and communicate with physicians on clinical issues</li><li>
CDI Credential (CCDS or CDIP)</li><li>
Bachelor of Science in Nursing or Medical School Graduate</li><li>
Ability to maintain a work pace appropriate to the workload</li><li>
Ability to influence and work collaboratively with physicians and all levels of staff</li><li>
Ability to establish and maintain effective working relationships across the Health System</li></ul><div><b><br>
Preferred Qualifications:</b></div><ul><li>
Previous experience with comprehensive chart / record review</li><li>
Master&rsquo;s degree with an emphasis in health care related fields (nursing, epidemiology, etc.)</li><li>
Knowledge of University and medical center organizations, policies, procedures and forms</li><li>
Experience working within EPIC and 3M 360 Encompass CAC</li><li>
CCS credential</li></ul><div><b><br>
Total Rewards</b></div><div>
We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits.</div><div></div><div><b><br>
Conditions of Employment:</b></div><div>
The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community. As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment:</div><ul><li>
Background Check and Live Scan</li><li>
Employment Misconduct*</li><li>
Legal Right to Work in the United States</li><li>
Vaccination Policies</li><li>
Smoking and Tobacco Policy</li><li>
Drug Free Environment</li></ul><div></div><ul><li><br>
<i>Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.
</i></li></ul><div>The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements.</div><ul><li>
California Child Abuse and Neglect Reporting Act</li><li>
E-Verify</li><li>
Pre-Placement Health Evaluation</li></ul><div>
Details of each policy may be reviewed by visiting the following page: https://hr.uci.edu/new-hire/conditions-of-employment.php</div><div><b><br>
Closing Statement:</b>
</div><div>The University of California is 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, age, protected veteran status, or other protected categories covered by the UC Anti-Discrimination Policy.
<br>
<br>
We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable, and welcoming.
<br>
<br>
UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact UCI's Employee Experience Center (EEC) at eec@uci.edu or at (949) 824-0500, Monday - Friday from 8:30 a.m. - 5:00 p.m.</div></div>

CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days REMOTE

Prairie Lakes Healthcare System

<div>
 <strong>
  Job Summary
  <br/>
  <br/>
 </strong>
 Join our team and be a part of our mission to deliver accessible, high-quality, affordable, and compassionate healthcare. Prairie Lakes Healthcare System is an independent, non-profit healthcare system serving 10 counties in northeastern South Dakota and west-central Minnesota. Our team at Prairie Lakes makes a difference in the lives of patients and their loved ones.
 <br/>
 <br/>
 <strong>
  Position Summary
  <br/>
  <br/>
 </strong>
 Wage: 21.38-30.92
 <br/>
 <br/>
 Position type: Remote, Hybrid or Onsite in Watertown, SD
 <br/>
 <br/>
 This position is open to candidates who currently reside in South Dakota or Minnesota.
 <br/>
 <br/>
 This
 <strong>
  full-time position(40 hours per week)
 </strong>
 assigns ICD-10-CM and CPT/HCPCS codes and releases medical records for billing purposes. Works with Clinical Documentation Specialist to provide proper documentation to obtain the proper DRG. Maintains compliance with federal and state guidelines.
 <br/>
 <br/>
 <strong>
  Responsibilities
  <br/>
  <br/>
 </strong>
 Abstracts pertinent information from patient records assigning ICD-10-CM or HCPCS codes, creating APC or DRG group assignments.
 <br/>
 <br/>
 Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
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 <br/>
 Key charges for surgery, anesthesia, infusion services, Evaluation and Management levels for the emergency room and observation patients and clinic. Along with any additional required procedures.
 <br/>
 <br/>
 Answer questions for the Reimbursement Department and Quality Department.
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 <br/>
 Assign Emergency and Management levels for Professional Fees.
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 <br/>
 Monitors the NCCI edit report and communicates with the applicable departments to resolve the edits to have a clean claim be billed to Medicare.
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 <br/>
 Monitor NCD/LCD policies for medical necessity on outpatient and surgical claims.
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 <br/>
 Assist with creation of new service lines for CPT/HCPCs/APC and DRG reimbursement.
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 <br/>
 Keeps abreast of coding guidelines and reimbursement reporting requirements, bringing identified concerns to supervisor or department manager for resolution.
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 <br/>
 Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official guidelines.
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 <br/>
 Other duties may be assigned.
 <br/>
 <br/>
 <strong>
  JOB SPECIFICATIONS
  <br/>
  <br/>
 </strong>
 <strong>
  Education And/or Experience
  <br/>
  <br/>
 </strong>
 Associate's Degree or Bachelor's Degree in Health Information Management. RHIT/RHIA or any AAPC certification preferred. Coding experience or a strong training background in coding and reimbursement is preferred.
 <br/>
 <br/>
 <strong>
  Certificates, Licenses, Registrations
  <br/>
  <br/>
 </strong>
 RHIT, RHIA, CCS, and/or CCS-P certification status preferred. Coding certification preferred by the American Health Information Management Association.
 <br/>
 <br/>
 <strong>
  Computer Skills
  <br/>
  <br/>
 </strong>
 Microsoft applications, CPSI, 3M Encoder
 <br/>
 <br/>
 <strong>
  Benefits
  <br/>
  <br/>
 </strong>
 Prairie Lakes Healthcare System offers comprehensive benefits for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 403(b)-retirement plan, and generous paid time off to maintain a healthy home-work balance.
 <br/>
 <br/>
 Additional benefits for those qualifying include:
 <br/>
 <br/>
 <ul>
  <li>
   Flexible Spending Account
  </li>
  <li>
   Employee Assistance Program for mental health
  </li>
  <li>
   Education Loan Program
  </li>
  <li>
   Community discounts including the Prairie Lakes Wellness Center
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <em>
  Prairie Lakes Healthcare System has a Drug Free Workplace Policy. An accepted offer will require positive reference checks and pre-employment background screening as a condition of employment.
 </em>
</div>


Coding Specialist

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