Clinical Documentation Specialist II

The Smarter Choice for your Career! Come join one of Connecticut’s Top Workplaces, and a Magnet designated organization! At Middlesex Health, we have a unique combination of award-winning talent, world-class technology, and patient-first care that's making health care better. Through our affiliation with the Mayo Clinic Care Network, Middlesex Health has access to the most advanced medical knowledge and research available.

Department: Health Information Management Hours: 40 hours/week Shift: Days, 1st Shift Work Location: Remote/United States Position Summary: Facilitates the improvement in the quality, completeness and accuracy of clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and the HIM Coding and CDI staff, by performing concurrent and/or retrospective reviews.

May be expected to assume a leadership role for an area(s) of the CDI Workflow, as assigned. Improves documentation education by facilitating the accurate and complete documentation of services to ensure that appropriate reimbursement is received for patients with a DRG-based payer. Improves documentation quality by facilitating communication with providers to ensure that the medical record accurately reflects the services provided, acuity and severity of illness treated. Works closely with the Manager to ensure the accomplishment of organizational goals pertaining to CDI and Coding. Conducts timely follow-up reviews to ensure that issues discussed/clarified are resolved. Stays current with, develops and conducts on-going industry education. Assists with the implementation of new programs, trials and other initiatives on an on-going basis. Adheres to Federal statutes, Medicare guidelines, Hospital policies and procedures to ensure compliance with published regulatory requirements. Reports any problematic issue to the Manager, Coding that may have an impact on the coding area - to ensure timely resolution of the problem or concern. Upholds both the Connecticut Nurse Practice Act and American Nurses Association Scope and Standards of professional practice. (Only applies to nursing roles)