Clinical Documentation Specialist - Dr. MobiCare

*This is not a remote position. This is work from the Houston Office.

Job Description

A Clinical Documentation Improvement specialist (CDIS) reviews wound care, skilled

nursing facilities, long-term care, office visits, laboratory tests, and home health records

simultaneously to ensure that the clinical documentation accurately represents the

severity and quality of the patient's illness, as well as the procedures performed in

accordance with CMS and insurance policies.

Provides training and education to providers and coding staff as needed, and

communicates with physicians, clinicians, Coding and Billing Professionals, Nursing

staff and Care Management to ensure timely and accurate documentation. Additionally,

the CDI Specialist will perform focused reviews under the direction of the department

supervisor.

A monthly provider education program is conducted for new providers as well as

ongoing education for existing providers.

Analyzes all clinical documentation for opportunities for quality improvement.

Participate in clinical and medical staff meetings to ensure documentation is available to

support applicable diagnoses.

It is expected that 65 medical records will be reviewed daily with a quality rating of 98%

or greater.

Ensure that the coding and billing team receives regular training on clinical

documentation and coding.

Support one-on-one education for staff identified as having quality or productivity

deficiencies based on departmental audits. Conduct staff audits to ensure quality

indicators are met. Review findings with appropriate personnel.

Ensure workflow is optimized to maximize automated systems, assist in training new

staff, and graduate from an accredited nursing school with an AAPC or AHIMA coding

certificate is desired.

Eligibility

Certified Clinical Documentation Improvement Practitioner (CCDS/CDIP) license -

Required.

Wound care experience - Required.

Certified Coding Specialist (CCS) license – Required.

A working knowledge of healthcare reimbursement methods. An understanding of coding

conventions, CPT, Modifiers, LCD/NCD, NCCI edits, ICD 10 CM, and CMS coding and

billing policies is necessary. Ability to communicate effectively in both oral and written

form, analytical skills, ability to organize and prioritize tasks – Required.

Registered nurse or LVN - Preferred

CDIS with three (3) years of clinical experience in surgery, long-term care facilities –

Preferred

Excellent interpersonal skills to interact effectively with all levels of hospital staff,

providers, and nursing homes.

Pay - $55,000 - $80,000/ annum based on experience.

Location: 5850 San Felipe St, Houston, TX 77057, USA