Facilitates improvement in the overall quality and completeness of clinical documentation to support accurate coding assignment, severity of illness, and risk of mortality. Works extensively with providers and multidisciplinary team members to identify documentation opportunities, support query processes, and promote compliant documentation practices.
Key responsibilities include:
- Identifying and recording principal and secondary diagnoses, procedures, and working DRGs
- Performing concurrent reviews and re-reviews of selected admissions
- Initiating documentation queries to clarify records and support severity of illness
- Educating providers and staff on documentation guidelines and query processes
- Supporting compliance with CMS, Medicare, and coding and billing regulations
- Collaborating with Quality, Coding, and administrative teams to improve documentation and reporting
- Assisting with education and training for new associates and clinical staff
Requirements & Qualifications
Education
- High School Diploma or equivalent
Experience
- 3 years of inpatient acute care coding or CDI experience
- Or 3 years of clinical experience as a Registered Nurse in an inpatient acute care setting
- Or 3 years of clinical experience as a Licensed Practical Nurse in an inpatient acute care setting
- Preferred: experience in Risk Adjusted Coding or Evaluation and Management
- Preferred: 2 years of CDI experience
Skills
- Strong written and verbal communication skills
- Knowledge of healthcare compliance, revenue cycle operations, and auditing techniques
- Knowledge of anatomy, physiology, and medical terminology
- Analytical, problem-solving, organizational, and time management skills
- Proficiency with office software programs
- Ability to work independently with minimal supervision
Location
Columbus, Ohio, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
1 month ago