Clinical Documentation Specialist

• Location: Remote
• Facility: Saint Thomas Health
• Department: Clinical Documentation
• Schedule: Full-time | Days

• Completes admission reviews and assigns a working Diagnosis Related Group. Ensures the working DRG and other information are entered in the Clinical Documentation Improvement database.
• Initiates and maintains extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
• Collaborates 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.
• Maintains accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.

Licensure / Certification / Registration

• Required Credential(s):
  • One or more of the following:
    • Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained within 6 Months (180 days) of hire date or job transfer date.
    • Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained within 6 Months (180 days) of 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.
    • Licensed Compact State Registered Nurse credentialed from the Tennessee Board of Nursing 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.

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.