Clinical Data Specialist designs and maintains clinical quality databases. Queries databases, creates reports and analyzes data to comply with regulatory reporting requirements and support improvements in clinical effectiveness. Being a Clinical Data Specialist defines and tests new measures, validates data, and takes steps to automate and improve the data collection process. Requires a bachelor's degree. Additionally, Clinical Data Specialist typically reports to a supervisor or manager. The Clinical Data Specialist gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Clinical Data Specialist typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
Description:
•The Clinical Documentation Integrity (CDI) Specialist is accountable for reviewing patient medical records in the inpatient and/or outpatient setting to capture accurate representation of the severity of illness and facilitate proper coding.
•Validates coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.
•Documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care.
•Utilizes advanced knowledge of disease processes (pathophysiology), medications, and have critical thinking skills to analyze current documentation to identify gaps.
•Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality and effective coding.
•Understands and applies regulatory compliance related to documentation, coding and billing for all health insurance plans.
•Facilitates appropriate modifications to documentation through extensive interactions and collaboration with physicians, coding, case management, nursing and other care givers.
•Serves as an effective change agent as an educator and resource for physicians and allied health staff to improve the quality and completeness of the clinical documentation.
•Performs all duties and responsibilities in accordance with ethical and legal business procedures, compliant with federal and state statutes and regulations, official coding rules, guidelines and accepted standards of coding practice including appropriate clinical documentation policies.
Skills:
clinical documentation, coding, ccs, crc, epic
Top Skills Details:
clinical documentation, coding, ccs, crc
Additional Skills & Qualifications:
•Two-Four years of experience in an Clinical Documentation Improvement Educator (CDI) role.
•Demonstrated skills in analytical thinking, problem solving.
•Effective verbal and written communication including ability to present ideas and concepts effectively to physicians, management and other members of our healthcare team.
•Self-motivated and able to work independently without close supervision.
•Demonstrated ability to work well with others in a creative and challenging work environment.
•Must be able to work flexible hours which may include evenings and weekends as required to meet business needs.
Experience Level:
Expert Level
About TEKsystems:We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.
The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
About the Company:
TEKsystems
About TEKsystems:
Company Size:
5,000 to 9,999 employees
Industry:
Staffing/Employment Agencies
Founded:
0
Website:
https://www.teksystems.com/en/
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