Clinical Documentation Specialist

Title: Clinical Documentation Specialist

Location:  Put-In-Bay, Ohio, 43456 

Health Information Management

Job ID: 404411 

Full Time 

Day

Details

• Department:Case Management
• Schedule:Full-time, 1.0 Salaried
• Hospital:Ascension Columbia St. Mary's Milwaukee
• Location:Remote

Benefits

Paid time off (PTO)
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 community

Benefit options and eligibility vary by position. Compensation varies based on factors including, but not limited to, experience, skills, education, performance and salary range at the time of the offer.

Responsibilities

Facilitate 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.

Requirements

Licensure / Certification / Registration:

• 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.

Education:

• High School diploma equivalency with 2 years of cumulative experience OR Associate's
  degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

Additional Preferences

No additional preferences.

Why Join Our Team

Ascension Wisconsin has been providing rewarding careers to healthcare professionals since 1848. Operating 17 hospital campuses and over 100 related healthcare facilities from Racine to Appleton, you will find opportunities that allow you to create a career path you love, all while delivering compassionate, personalized care to the communities we serve.

Ascension is a leading non-profit, faith-based national health system made up of over 134,000 associates and 2,600 sites of care, including more than 140 hospitals and 40 senior living communities in 19 states.

Our Mission, Vision and Values encompass everything we do at Ascension. Every associate is empowered to give back, volunteer and make a positive impact in their community. Ascension careers are more than jobs; they are opportunities to enhance your life and the lives of the people around you.

Equal Employment Opportunity Employer

Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws.