Responsible for ensuring all conditions and treatments are accurately, completely, and compliantly documented in the medical record for proper MS-DRG and APR-DRG assignment, and for capturing severity-of-illness (SOI) and risk-of-mortality (ROM) levels. The role supports accurate reflection of the quality of care provided in accordance with CMS rules and regulations.
Works collaboratively with medical staff, HIM coders, quality improvement professionals, and other members of the healthcare team to achieve optimal outcomes. Stays current on industry changes affecting clinical documentation integrity and educates patient care team members on documentation guidelines and service-specific requirements.
Location: MetroHealth Medical Center
Biweekly Hours: 80.00
Shift: 7a-3:30p
Required
- One of the following credentials:
- RN licensure; BSN required if hired after April 2023
- RHIA (Registered Health Information Administrator)
- RHIT (Registered Health Information Technician) with a bachelor's degree
- Five years of experience in an inpatient acute care environment as a clinician or hospital inpatient coder
- Demonstrated knowledge and proficiency with clinical information systems and office automation
- Strong understanding of pathophysiology and disease management
- Broad clinical background
- Excellent verbal and written communication skills
- Strong critical thinking skills
- Ability to work effectively with medical providers and manage multiple tasks and educational activities
- Ability to work independently and be self-directed
- Ability to travel to various clinical areas as assigned
- Ability to interact effectively with diverse cultural, ethnic, racial, and socioeconomic backgrounds
Preferred
- Active CCDS certification from ACDIS
- Active CDIP certification from AHIMA
- Graduate degree in a related field
- One to three years of inpatient clinical documentation improvement experience in a tertiary academic healthcare system
- Working knowledge of Medicare reimbursement and ICD-10 coding structures
- Experience with EPIC electronic medical record and 3M 360 Encompass systems
- Proficiency with Microsoft Word, Excel, and PowerPoint
Physical demands
- May require intermittent movement throughout the day, including sitting, standing, stooping, bending, and ambulating
- May require remaining still for extended periods
- Must be able to communicate via face-to-face, phone, email, and other methods
- Must be able to read job-related documents and use a computer
Location
Cleveland, Ohio, US
Employment Type
Full-time
Experience Level
Senior
Remote work allowed
No
Posted
4 weeks ago