Clinical Doc Spec PRN - Remote Eligible

Job Summary

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work Shift Day (United States of America)

Core Responsibilities and Essential Functions

The PRN Clinical Documentation Specialist (CDS) has strong knowledge and skills in clinical and coding concepts to enhance the quality and precision of the clinical documentation in the patient record on a concurrent, and possibly prospective and/or retrospective basis, using team-based processes. The PRN CDS cooperates with physicians, other healthcare professionals and coding team to make sure that the medical record contains accurate and complete clinical information that reflects the appropriate utilization, clinical severity, outcomes, and quality for the level of service provided to all patients, as well as ensuring compliant payment for patient care services. PRN CDS must communicate and collaborate well with CDI Leadership to offer CDI support as and when required to help the CDI department and organization achieve clinical and operational excellence in Clinical Documentation Improvement efforts.

Required Minimum Education

• Associates Nursing or Bachelors Health Science or Bachelors Nursing or Doctorate Medicine

Required Minimum License(s) and Certification(s)

• Cert Coding Spec or Cert Prof Coder or Reg Health Information Admin or Reg Health Information Tech or Reg Nurse (Single State) or RN - Multi-state Compact
• Cert Document Improvement Prac-Preferred or Cert Clin Document Specialist-Preferred

Additional License(s) and Certification(s)

It is expected that all RN's are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Upon Hire Required or It is expected that all non-clinical (coding) background candidates have at least one of following active/current certifications: (1) Certified Coding Specialist (CCS) from AHIMA, (2) Certified Professional Coder (CPC) from AAPC, (3) Registered Health Information Administrator (RHIA) from AHIMA, or (4) Registered Health Information Technician (RHIT) from AHIMA Upon Hire Required or It is expected that all MD/IMG candidates should have a completed degree from an accredited medical school. Upon Hire Required

Required Minimum Experience

Minimum 2 years of working in an acute care setting as a Clinical Documentation Specialist (CDS) Required and Minimum 5 years of healthcare experience Required and Epic and Solventum/3M 360 Encompass experience is required Required and Prior experience of working as a CDI/Coding auditor is preferred Preferred and Prior experience of working in inpatient case management or utilization review is preferred Preferred

Required Minimum Skills

Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR) Epic and Solventum/3M 360 Encompass experience is required Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives Excellent communication skills, employing tact and effectiveness Demonstrate effective communication skills and collaborates with medical staff, clinical departments, and key facility leadership team members Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives Excellent problem-solving skills, with the ability to recommend and implement practical and efficient solutions Must have proficient computer skills in Microsoft Apps, such as Word, Excel and PowerPoint, as well as CDI technology tools required for the job functions Drives optimal use of the CDI technology tool and reporting capabilities

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.