Clinical Documentation Review Specialist, Robert Half

Robert Half

Location:
United States, Rancho Cordova

Category:
Health and Beauty

Contract Type:
Employment contract

Salary:

Not provided

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Job Description:

This role involves a meticulous examination of hospital medical documentation, communication with medical staff, and ensuring appropriate reimbursement for the hospital reflecting the complexity and severity of patient care.

Job Responsibility:

Evaluate medical record documentation concurrently on the nursing units to guarantee clear and comprehensive documentation by physicians
Engage with physicians concerning missing, unclear, or conflicting medical record documentation and secure additional documentation within the medical record to assist with the correct code assignment
Offer documentation and coding education to patient care providers
Participate in retrospective chart reviews to assess the effectiveness of physician prompting
Contribute to the analysis and trending of statistical data for specified patient populations to identify areas for improvement
Ensure accurate completion of worksheets for performance tracking reports
Make decisions about the interpretation and clarification of inpatient documentation and determine when to prompt physicians for more complete documentation affecting hospital reimbursement
Accurately and effectively identify missing documentation through clinical review and communicate with physicians and patient care teams regarding additional or more complete documentation opportunities
Manage compliance with Medical Staff Rules and Regulations regarding documentation requirements, understanding coding and legal guidelines established by external regulatory agencies and following state and organization patient confidentiality policies.

Requirements:

Minimum of 5 years of experience in a healthcare setting, preferably within the NHS
Demonstrable skills in Auditing, particularly within a healthcare context
Proficiency in Health Information Management (HIM)
Experience with Electronic Medical Records (EMR) is essential
Ability to perform Medical Records Analysis and Medical Records Review effectively
Familiarity with Clinical Data Interchange Standards Consortium (CDISC) protocols
Knowledge of All Patient Refined Diagnosis Related Groups (APR DRG) and All Patient Diagnosis Related Groups (AP-DRGs) is required
Experience with Health Care Audits, specifically within the Medicare and Medicaid systems
Comprehensive understanding of Medicare regulations and guidelines.

What we offer:

Medical, vision, dental, and life and disability insurance
Eligibility for company 401(k) plan
Competitive compensation
Free online training.

Additional Information:

Job Posted:
May 08, 2025

Employment Type:

Fulltime

Work Type:

On-site work

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Clinical Documentation Review Specialist