Clinical Documentation Improvement Specialist

Oneida Health is a healthcare organization seeking a Clinical Documentation Improvement Specialist to improve the accuracy and completeness of clinical documentation in its Meditech electronic health record system. The role reviews patient records, collaborates with healthcare professionals on coding clarification, analyzes documentation trends, and provides education and training to support compliance and documentation quality.

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

Preferred

• * Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Coding Specialist (CCS) certification preferred
• Certified Clinical Documentation Improvement Specialist (CCDS)
• Certified Coding Specialist (CCS)

Benefits

• Hybrid work arrangement

Company

• Integrated health network offering primary and specialty care
• Oneida, New York, USA
• https://www.oneidahealth.org/
• Founded in 1899
• 1001-5000 employees

Qualifications

• This role requires attention to detail, a deep understanding of clinical documentation, and the ability to foster collaboration among healthcare professionals
• * Ability to navigate and review electronic health records
• * Regular use of computer and office equipment
• * Bachelor's degree in nursing, health information management, or relevant field; prior experience will be considered
• * Clinical experience in a healthcare setting, preferably in a hospital environment
• * Proficiency in working with Meditech EHR system
• * Strong knowledge of coding guidelines, healthcare regulations, and clinical documentation requirements
• * Excellent communication and interpersonal skills
• * Ability to collaborate effectively with multidisciplinary teams
• * Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Coding Specialist (CCS) certification preferred

Required skills

• Meditech EHR, Clinical Documentation, Medical Coding, Coding Guidelines, Healthcare Regulations, Clinical Experience, Certified Clinical Documentation Improvement Specialist (CCDS), Certified Coding Specialist (CCS)

Experience

• Mid level