Clinical Documentation Specialist
- Muskego, WI
- $75,295 per year
- Permanent
- Full-time
- Department: Case Management
- Schedule: Full-time, 1.0 Days
- Hospital: Ascension Columbia St. Mary's Milwaukee
- Location: Remote
- Salary: $75,295.00-104,7957.00 per year
Various health insurance options & wellness plans
Retirement benefits including employer match plans
Long-term & short-term disability
Employee assistance programs (EAP)
Parental leave & adoption assistance
Tuition reimbursement
Ways to give back to your communityBenefit options and eligibility vary by position. Compensation varies based on factors including, but not limited to, experience, skills, education, performance, location and salary range at the time of the offer.ResponsibilitiesFacilitate improvement in overall quality, completeness and accuracy of medical record documentation.
- Complete admission reviews and assigns a working Diagnosis Related Group. Ensures the working DRG and other information are entered in the Clinical Documentation Improvement database.
- Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
- Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.
- Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.
- One or more of the following required:
- Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
- Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
- Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
- Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
- Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
- Registered Nurse credentialed from the Wisconsin Board of Nursing obtained prior to hire date or job transfer date. Licensure from the Wisconsin Board of Nursing OR current home state license if considered multi-state/Compact State.
- High School diploma equivalency with 2 years of cumulative experience OR Associate's