Clinical Documentation Improvement Specialist
Description:
RESPONSIBLE FOR:
Reviewing clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician's clinical documentation. This work involves extensive record review and interaction with physicians, HIM/Coding professionals, nursing staff, and case management. Through collaboration with Coding professionals, educates the patient care team on changes in documentation guidelines and/or documentation deficiencies noted. The patient care team includes but is not limited to: attending physicians, consultants, physician extenders, allied health practitioners, nursing, and case management. The Specialist reports to the Clinical Documentation Improvement Director.
Qualifications:
MINIMUM EDUCATION REQUIRED:
Associate's Degree from a program of nursing, BSN preferred, or Associate's Degree in Health Information Management
MINIMUM EXPERIENCE REQUIRED:
Minimum of five (5) years of recent hospital experience/practice, preferably in an ICU, CCU or complex Med/Surg environment.
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
ADDITIONAL QUALIFICATIONS:
A current state Registered Nurse license or Certified Coding Specialist, RHIT, RHIA, OR CCDS. Bachelors preferred. Previous clinical documentation improvement experience, utilization management, precertification, coding, Medicare regulations, quality assurance, or related area preferred. Knowledge of DRG, ICD-9/10 and CPT coding relative to physician clinical documentation within electronic medical records preferred. Prior experience with Epic preferred.
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Piedmont. Real Change Lives Here.
Piedmont is empowering Georgians by changing health care. We continue to fuel Georgia s growth through safe, high-quality care close to home through an integrated health care system that provides a hassle-free, unified experience. We are a private, not-for-profit organization that for centuries has lived up to our purpose to make a positive difference in every life we touch in the communities we serve.
Across our 1,755 physical locations we care for more than 4 million patients and serve communities that comprise 85 percent of Georgia s population. This includes 25 hospitals, 75 Piedmont Urgent Care centers, 25 QuickCare locations, 1,875 Piedmont Clinic physician practices and nearly 3,200 Piedmont Clinic members. Our patients conveniently engage with Piedmont online, as they scheduled more than 612,000 online appointments and over 163,000 virtual visits.
With more than 47,000 care givers we are the largest Georgia-based employer of Georgians, who all came for the job, but stayed for the people. In 2024 and 2023, Piedmont has earned recognition from Newsweek as one of America s Greatest Workplaces for Diversity and also as one of America's Greatest Workplaces for Women. In 2022, Forbes ranked Piedmont on its list of the Best Large Employers in the United States. In addition, Piedmont provided nearly $390 million in community benefit programming and uncompensated care in Fiscal Year 2023.