Clinical Documentation and Compliance Specialist

Now Hiring: Clinical Documentation Specialist!

 

Presbyterian is seeking for a Clinical Documentation Specialist.  This position requires a proactive individual with the confidence to address documentation concerns while maintaining positive relationships with medical staff. If you’re ready to make a meaningful impact in clinical documentation, we’d love to hear from you!

We are seeking a detail-oriented Clinical Documentation Specialist to assist medical staff providers with accurate documentation in the medical record. This role involves daily review of physician documentation, tracking patient diagnoses and procedures, and ensuring that the level of service provided is accurately reflected.

 

Key Responsibilities:

• Review physician documentation daily for accuracy and completeness.

• Track patient diagnoses and procedures to ensure appropriate service levels are documented.

• Work closely with physicians and staff to verify that clinical information is accurately captured.

• Address clinical documentation issues with confidence, ensuring compliance with regulatory requirements.

• Communicate effectively with medical staff, resolving any concerns about documentation needs.

• Maintain professionalism and tact while obtaining medical staff cooperation.

Qualifications:

• Strong understanding of clinical documentation and regulatory guidelines.

• Excellent communication and collaboration skills.

• Ability to work independently and prioritize tasks effectively.

• Experience handling documentation challenges and ensuring compliance.

• Team player with a flexible approach to workload management.

Why Join Us

• Full Time - Exempt: Yes
• Job is based at Presbyterian Hospital
• Remote work from home: this job is intended to be conducting in the state of New Mexico.
• Work hours: Weekday Schedule Monday-Friday
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

Ideal Candidate:

The ideal candidate will work independently, managing and prioritizing their workload to ensure all tasks are completed efficiently. Flexibility is essential to assist with coverage needs, and collaboration with other reviewers and HIM coders is expected.

• Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelors degree with 2 yrs CDI experience required.
• Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS).
• Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes and related procedures required.
• Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required.
• Experience with database, spreadsheet and word process required.
• Detail and results oriented, with the ability to maintain accurate, detailed and organized records essential.
• Education specialization: Nursing

 

• Responsible for clinical documentation analysis of the medical record, documentation completeness, coding accuracy and compliance in either electronic or hard copy form as designated.
• Performs concurrent reviews of the medical record for inpatient admissions to include assignments of DRG, identifying complication and co-morbid conditions and specific co-existing conditions and documents findings.
• Works collaboratively with the Medical Staff, Nursing Staff and other patient care givers to improve the quality of chart documentation to accurately reflect services provided and present an accurate hospital and physicians profile.
• Assist physicians with documentation requirements to support medical necessity for hospital and physician billing.
• Interprets clinical information in the medical record, ordered interventions, lab and test results, etc., and queries if necessary, for supporting documentation in progress notes, consultations, history and physicals, etc., as appropriate.
• Initiates communication to physicians, providers, verbally or utilizing the appropriate prompter/query tools, in order to obtain more specific principal diagnosis or co morbidities and complications. Solicit clarification of existing documentation in the medical record that support patient severity of illness.
• Acts as expert clinical resource for the HIM Coding team, working collaboratively to identify areas for clarification of documentation in the medical record that meets regulatory requirements to accurately reflect patient severity of illness and services provided.
• Coordinates with the HIM Coding team related to coding guideline requirements for clinical documentation.
• Collaborates with the HIM Coding team to provide information and education as necessary to physician and other providers not responding to prompters/ queries on documentation requirements.
• Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. This includes but is not limited to all ICD-10, CPT, HCPCS and APC updates and changes. This includes but is not limited to CMS, JCAHO, Nursing Standards of Practice, etc.
• Maintains up-to-date working knowledge of all PHS coding and documentation IT applications.
• Maintains current knowledge of Nursing Practice through seminars, workshops, publications, etc.
• Conducts training classes in areas of coding, documentation and compliance for physicians and other providers. This includes preparation of training materials, educational audits and answering situational questions.
• Serves as a liaison to other departments, providing clinical expertise and consultation.
• Utilizes monitoring tools to track defined measures for progress of documentation accuracy

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

USD $44.49/Hr.

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.