Job Title: Clinical Documentation Improvement Specialist
Job Summary:
As a Clinical Documentation Improvement Specialist, you play a pivotal role in elevating the accuracy and completeness of clinical documentation within the electronic health record (EHR) system, specifically utilizing the Meditech platform. Your primary responsibilities include conducting comprehensive reviews of patient medical records, collaborating with healthcare providers to ensure accurate coding, and implementing strategies for documentation improvement. Through education and training initiatives, you contribute to enhancing the overall quality of documentation, complying with coding guidelines, and fostering effective communication among multidisciplinary teams.
Key Responsibilities:
- Conduct thorough reviews of patient medical records to identify opportunities for enhanced documentation accuracy.
- Collaborate with physicians, nurses, and other healthcare professionals to obtain clarification and additional information supporting precise coding.
- Educate and train clinical staff on best practices for documentation improvement and coding guidelines.
- Analyze coding and documentation trends to identify areas for process improvement and implement strategies to address deficiencies.
- Assist in developing and implementing policies and procedures related to clinical documentation improvement.
- Stay updated on changes in coding guidelines, regulations, and Meditech updates to ensure compliance and adherence to best practices.
Requirements:
This role requires attention to detail, a deep understanding of clinical documentation, and the ability to foster collaboration among healthcare professionals. If you are passionate about enhancing the quality of healthcare documentation and ensuring compliance, we invite you to apply for this impactful position.
Physical Requirements:
- Ability to navigate and review electronic health records.
- Regular use of computer and office equipment.
Education:
- Bachelor's degree in nursing, health information management, or relevant field; prior experience will be considered.
Experience:
- Clinical experience in a healthcare setting, preferably in a hospital environment.
Certifications:
- Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Coding Specialist (CCS) certification preferred.
Technical Skills:
- Proficiency in working with Meditech EHR system.
- Strong knowledge of coding guidelines, healthcare regulations, and clinical documentation requirements.
Soft Skills:
- Excellent communication and interpersonal skills.
- Ability to collaborate effectively with multidisciplinary teams.
Skills Required
- Bachelor's degree in nursing, health information management, or relevant field (prior experience considered)
- Clinical experience in a healthcare setting, preferably a hospital environment
- Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Coding Specialist (CCS)
- Proficiency in Meditech EHR system
- Strong knowledge of coding guidelines, healthcare regulations, and clinical documentation requirements
- Excellent communication and interpersonal skills; ability to collaborate with multidisciplinary teams
- Ability to navigate and review electronic health records and regular use of computer/office equipment
What We Do
Oneida Health is a nonprofit healthcare provider dedicated to providing high-quality, progressive, and comprehensive health care services for the greater Oneida area and surrounding communities. Operated by Oneida Health Systems, Inc., the organization includes a 101-bed acute care hospital, emergency department, surgery center, and a 160-bed extended-care and short-term rehab facility, along with various specialty care offices and diagnostic services.
