Job#: 1309274

Job Description:

Clinical Documentation Improvement Specialist

Title: Clinical Documentation Improvement Specialist

Location: Aurora, IL  (Onsite 3 days/Remote 2 days)

Pay on Contract: $30.00 - $40.00 (Based on experience)

Salary Conversion: $64,000 - $80,000 (Based on experience)

Contract: 3 month contract to permanent hire

REQUIREMENTS

• License to practice as a Registered Nurse
• 3 years of medical or surgical acute care nursing experience
• Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist).
• Three years of inpatient coding experience.
• Clinical Documentation Specialist experience in an acute care hospital preferred. OR Graduate from an accredited medical school, either foreign or domestic, with a CCDS (Certified Clinical Documentation Specialist) credential and minimum of one year experience working as a Clinical Documentation Specialist in an acute care hospital.

Job Description:

• Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation.
• Facilitates necessary documentation in the medical record through extensive interaction with physicians, nursing staff, other patient caregivers, and collaboration with HIM coding staff to ensure the most appropriate reimbursement is achieved for the level of service rendered to all patients.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and pay for performance diagnosis specific quality outcomes.
• Oversees clinical documentation patterns and trends to identify areas of improvement for the pay for performance measures.
• Educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and pay for performance documentation requirements on an on-going basis.
• Develops and conducts on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals. Compiles, analyzes and evaluates quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements.

EEO Employer

Apex Systems is an equal opportunity employer. We do not discriminate or allow discrimination on the basis of race, color, religion, creed, sex (including pregnancy, childbirth, breastfeeding, or related medical conditions), age, sexual orientation, gender identity, national origin, ancestry, citizenship, genetic information, registered domestic partner status, marital status, disability, status as a crime victim, protected veteran status, political affiliation, union membership, or any other characteristic protected by law. Apex will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law. If you have visited our website in search of information on employment opportunities or to apply for a position, and you require an accommodation in using our website for a search or application, please contact our Employee Services Department at employeeservices@apexsystems.com or 844-463-6178.