Clinical Documentation Improvement Specialist; Cert. Coder or RN

Essential Functions

The Clinical Documentation Improvement Specialist (CDIS) is responsible for educating clinical staff, improving documentation of all conditions, treatments, and care plans to ensure the highest quality of care is provided to the patient.

• Understand and comply with the laws and regulations governing job activities and the ethical and legal standards set forth in the Nor-Lea Compliance Program Plan and Code of Conduct.
• Evaluate medical record documentation and coding to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support visits and to ensure that data complies with legal standards and guidelines.
• Make recommendations for changes in policies and procedures.
• Educates and advises staff on proper code selection, documentation, procedures, and requirements.
• Identify training needs, prepare training materials, and conduct training for physicians and support staff to improve skills in the collection and coding of quality health data.
• Assist in ensuring quarterly provider E/M audits are performed, reported and follow-up education is performed.
• Responds and assists customers immediately upon request and follows up on previous interactions to ensure issue resolution, escalation, or issue closure as appropriate.
• Serve as subject matter expert (SME) of Clinical Documentation. Assist, investigate, and solve documentation concerns with recommendations to clinical departments and hospital staff.
• Able to effectively communicate with other end users and be perceived as approachable and reliable.

• Ability to effectively build relationships with customers through positive interaction
• Ability to work independently
• Ability to prioritize responsibilities and to organize workload to ensure that time frames are met
• Problem solving
• Ability to develop training materials, make group presentations, and to train staff
• Knowledge of ICD-10-CM and CPT coding guidelines; medical terminology; anatomy and physiology; state and federal Medicare reimbursement guidelines
• Ability to identify, analyze, and effectively address complex issues

• 2 years working in an EPIC or other EHR environment

• High School Diploma or General Educational Development (GED) Required

• Certification in Clinical Documentation Improvement preferred
• Certification in Coding preferred
• Associate of Applied Science