Clinical Documentation Specialist

Park Ridge Child Care Center Inc

Rochester, NY, US
Base: $78,000.00 - $95,000.00; bonus/equity: not s...
Fully remote
3-5 years acute care experience
Review medical record completeness
Knowledge of medicare part a guidelines
The Clinical Documentation Specialist facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care, and quality in the medical record

Job Summary

  • The Clinical Documentation Specialist facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care, and quality in the medical record.
  • Candidates must have 3-5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU settings.
  • The role requires effective communication with physicians to formulate clinically credible documentation clarifications and resolve discrepancies with HIM staff.

Matching Summary

The Clinical Documentation Specialist facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care, and quality in the medical record.

Salary

Base: $78,000.00 - $95,000.00; Bonus/Equity: Not specified; Benefits: Not specified

Skills & Requirements

Must-have

  • 3-5 years acute care experience
  • Review medical record completeness
  • Knowledge of Medicare Part A guidelines
  • ICD-10-CM coding application
  • Critical thinking and problem solving

Nice-to-have

  • Organizational and interpersonal skills
  • Self-directed and dependable attitude
  • Experience with PDPM calculator tool
  • Familiarity with Windows software
  • Ability to educate care team members

Key Requirements

  • Registered Nursing degree required
  • Valid RN license in New York State
  • CCDS certification within 30 months if hired after Jan 1, 2017
  • Bachelor's degree preferred
  • 3-5 years clinical experience

Work Rights

Not specified

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