CDI/CODER III

ON-SITE POSITION

The Clinical Documentation Specialist (CDS)/Coder III is responsible conducting clinically based concurrent and retrospective reviews of inpatient medical records. This review is to evaluate that the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided. The CDS will work closely with the medical staff to facilitate appropriate clinical documentation of patient care. The CDS/Coder III abstracts and codes the diagnostic and procedural information for Inpatient Services and Surgery medical records utilizing the current version of International Classifications of Diseases in accordance with regulatory agencies and hospital specific guidelines. The CDS/Coder III enters the coded data and other abstracted data from the medical record into the electronic information system. This position assumes primary responsibility for clarifying ambiguous documentation, DRG optimization with the primary role in assisting medical staff members with improving quality of documentation, and serves as a mentor to all level of Coders and CDIs. Participates in chart review projects as assigned.

Requirements:

1. Medical Graduate, PA, RN, LVN, RHIT or CCS with current valid license/certification and relevant education.

2. CCS Certification Required

3. CDIP and/or CCDS Certification Preferred

4. Minimum of 2+ year’s clinical experience in an acute care setting or 5 years of acute care inpatient coding.

5. Knowledge of care delivery documentation systems and related medical record documents

6. Knowledge of the elements of disease processes and related procedures

7. Strong clinical knowledge and understanding of pathology / physiology of disease processes

8. Excellent written and verbal communication skills. Excellent critical thinking skills

9. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff

10. Working knowledge of inpatient admission criteria, preferred

11. Ability to work independently in a time-oriented environment

12. Computer literacy and familiarity with the operation of basic office equipment

13. Assertive personality traits to facilitate ongoing physician communication

14. Working knowledge of Medicare reimbursement system and coding structures preferred

Benefits: 

• Medical, dental and vision coverage is provided for all full time and part time employees* 
• Medical is 100% employer paid including dependents* 
• Employee Stock Ownership Program 
• Basic Life and AD&D 
• 401k plan with company match 
• Generous PTO plan* 
• Pet Insurance Discount Program* 
• Employee Discount Program*
• *per diem staff ineligible

The posted pay scale represents the range the Company reasonably expects to pay candidates for this position. The actual wage for this position may depend on factors such as experience and education, specific skills and abilities, alignment with similar internal candidates, marketplace factors, an applicable collective bargaining agreement, and Company business practices.