About the position
The Specialist, Clinical Document position at Genesis Health System involves utilizing advanced clinical and coding expertise to ensure the integrity of clinical documentation. The role focuses on reviewing medical records, educating healthcare providers, and ensuring accurate coding to support medical necessity and quality outcomes. This fully remote position requires extensive interaction with healthcare teams to enhance documentation practices and compliance with regulations.
Responsibilities
• Utilize advanced clinical and coding expertise to ensure the integrity of clinical documentation.
• Conduct extensive record reviews to ensure quality, completeness, and accuracy of medical records.
• Educate physicians and healthcare team members on clinical documentation best practices.
• Perform concurrent reviews of patient health records for clarity and completeness.
• Formulate compliant clarifications and queries following documentation integrity procedures.
• Collaborate with coding staff to ensure accurate documentation of diagnoses and co-morbidities.
• Demonstrate problem-solving skills and serve as a professional role model.
• Leverage 3M/360 functions for data entry related to CDI efficiencies.
• Maintain knowledge of applicable laws, regulations, and organizational policies.
Requirements
• Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or an Advanced degree in nursing or Physician Assistant.
• Preferred certifications include Registered Nurse License, RHIA, RHIT, CCS, CCDS, or CDIP.
• Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, or as an inpatient coder is preferred.
• Excellent verbal and written communication skills, with strong interpersonal and collaboration abilities.
• Demonstrated ability to use standard desktop and Windows-based computer systems, including email and internet navigation.
• Data entry skills with a minimum typing speed of 30 wpm.
• Ability to work independently and collaboratively in a remote environment.
Nice-to-haves
• Experience with databases, spreadsheet software, and presentation software.
• Strong critical thinking and organizational skills.
• Effective presentation and facilitation skills.
Benefits
• Fully remote work environment
• Competitive salary range from $29.28 to $43.92 per hour
• Opportunities for professional development and education