Maxim Healthcare Services, Inc.
The Clinical Documentation Specialist reviews medical records while a patient is in the hospital, and identifies documentation needs in the medical record. They communicate, either verbally or in writing, with physicians to clarify documentation in the medical record.
Essential Duties and Responsibilities:
Provides CDI instruction to classes of nurses, CDI coding professionals, and other ancillary personnel.
Coordinates types and numbers of reviews each day with the needs presented
Reviews medical records concurrently (while patient is in the hospital), or retrospectively per client request
Reports to the designated manager in the hospital
Serves as an employee with all the requirements set forth by Company structure
Meets clients’ minimum agreed review rates (generally no more than 25 new admissions and reviews combined per day)
Facilitates communication among coders, physicians, and utilization nurses to identify documentation opportunities
Teaches MDC methodology to the client, identifying CDI opportunities for documentation clarification
Leads CDI-applicable presentations to Ancillary department (Physical Therapy, Nursing, Dietary, etc.)
Coordinates classroom presentations
Performs other duties as assigned/necessary
Must hold at least one of the following certifications: RN
Minimum of 24 months of CDIS application experience within the last three years of application
Must possess and utilize knowledge of the CDI review process, CDI strategies, compliant CDI query technique, and non-leading provider communication.
Must be trained in ICD-10-CM/PCS and provide evidence of training.
Must be willing and able to travel, or work remotely, based on assignment
Must be willing and able to travel on-site as required by the client, based on assignment needs
(i.e. training, etc.) perform on-site three weeks in a row (any more will be cleared through MHIS CDIS)
Ability to effectively elicit/provide information to and from appropriate individuals (including, but not limited to, supervisors, co-workers, clients) via strong communication skills; proficiency in the English language may be required
Computer proficiency required
Must be at least 18 years of age
At Maxim Healthcare Services, we firmly believe that our caregivers are the heartbeat of our organization and we are happy to offer the following benefits:
Competitive pay & weekly paychecks
Health, dental, vision, and life insurance
401(k) savings plan
Continuous professional and clinical training
Awards and recognition programs
*Benefit eligibility is dependent on employment status.
Maxim Healthcare Services is a leading provider of home healthcare, medical-related staffing, travel nursing, and population health and wellness services across the United States. As an established community partner, we have been making a difference in the lives of our employees, caregivers, and patients for more than 25 years. Our commitment to customer service, improving patient care, and staffing experienced healthcare professionals has paved the way for many rewarding career opportunities in the healthcare industry.
Maxim Healthcare Services, Inc. is an Affirmative Action/Equal Opportunity Employer
Maxim Healthcare Services, Inc.
Website : http://www.maximstaffing.com/
We specialize in providing contract, temp-to-perm, per diem, and direct hire personnel to practically every segment of the healthcare market. We invite you to discover what makes Maxim Staffing Solutions one of the leading medical staffing agencies in the nation. Contact us today to learn more about our staffing solutions. If you are a job seeker, we offer a variety of positions in the healthcare industry, including nursing jobs, Allied Health jobs, physician jobs, health information management jobs, and more.