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Role Description

This role involves reviewing clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care.

• Improve the quality of the physician's clinical documentation
• Conduct extensive record review and interact with physicians, HIM/Coding professionals, nursing staff, and case management
• Educate the patient care team on changes in documentation guidelines and/or documentation deficiencies noted
• Collaborate with Coding professionals
• Report to the Clinical Documentation Improvement Director

Qualifications

• Associate’s Degree in nursing, Health Information Management or a related field (Required)
• Bachelor’s Degree (Preferred)
• 5 years of recent hospital experience/practice, preferably in an ICU, CCU or complex Med/Surg environment (Required)
• Previous clinical documentation improvement experience, utilization management, precertification, coding, Medicare regulations, quality assurance, or related area (Preferred)
• Prior experience with Epic (Preferred)

Requirements

• Must have one of the following upon hire (Required):
• RN - Registered Nurse - Georgia State Licensure and/or NLC/eNCL Multistate Licensure
• CCS - Certified Coding Specialist
• RHIT - Registered Health Information Technician
• RHIA - Registered Health Information Administrator
• CCDS - Certified Cardiac Device Specialist

Company Description

Piedmont Healthcare is committed to providing exceptional patient outcomes and supporting the career growth of its employees.