01Key Responsibilities
Documentation Review: Conduct regular audits of clinical documentation in the Emergency Medicine department to identify areas for improvement, ensuring accuracy and completeness.
Education and Training: Provide ongoing education to emergency medicine staff on best practices for clinical documentation, including coding guidelines and regulatory compliance.
Collaboration: Work closely with coders, QA staff, leadership, clients, physicians, and clinical staff to clarify documentation issues and promote accurate coding.
Data Analysis: Analyze documentation trends to identify opportunities for improvement in clinical practices and documentation accuracy.
Compliance Monitoring: Ensure adherence to CMS guidelines and other regulatory requirements related to clinical documentation.
Feedback and Reporting: Develop and present reports on documentation improvement initiatives and outcomes to supervisors, stakeholders, and senior leadership.
Quality Improvement: Participate in initiatives aimed at enhancing patient care and safety in the Emergency Medicine department.
Professional Development: Stay updated with clinical documentation and coding standards through continuing education and professional organizations.
Qualifications:
Education: Bachelor's or Masters degree in a life sciences field such as Medicine, Physiotherapy, Occupational Therapy, Physician Assistant, Nursing, Pharmacy, Biomedical Sciences, Biochemistry, Microbiology, or Health Information Management.
Experience: Minimum of 4-5 years of clinical experience in an Emergency Medicine setting, with at least 2 years in clinical documentation improvement or coding.
Certifications: CPC, Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP), or equivalent certification preferred.
Skills: Strong knowledge of medical terminology, anatomy, physiology, coding guidelines (ICD-10, CPT, Modifiers, Category II codes), and clinical documentation standards. Excellent communication, analytical, and problem-solving skills.
Technology Proficiency: Familiarity with electronic health record (EHR) systems and clinical documentation improvement software.
Work Environment:
Primarily based in the Emergency Medicine department with interactions across various departments.
Ability to work in a fast-paced clinical environment during US shift hours.
Work from office is mandatory. .
