Hybrid Clinical Documentation Improvement Specialist en None

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. 

Essential Functions: 

•    Understand and comply with the laws and regulations governing my job activities and the ethical and legal standards set forth in the Nor-Lea Compliance Program Plan and Code of Conduct.
•    Evaluates 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. 
•    Identifies training needs, prepares training materials, and conducts 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.
•    Serves 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 is perceived as approachable and reliable.