The Clinical Documentation Specialist is responsible for auditing clinical documentation in the medical record to ensure compliance with regulatory requirements and managed care contracts.
Audits include review of the entire patient encounter from registration through discharge to identify inaccuracies and delinquencies and to provide education on documentation requirements.Act as a documentation regulatory expert by remaining up to date with federal, state, and organizational guidelines related to documentationConducts regular and ad hoc documentation audits to identify errors and facilitates improvement.Cross references managed care contracts for required documentation for payment and reports discrepancies with a corrective action plan.Keeps abreast of all organizational processes and Cerner updates, in addition to pertinent state and federal regulatory updates that may affect documentation requirements.Researches the industry and state specific regulatory and payor documentation policy changes in a timely manner.Performs risk assessments and gap analysis of the clinical documentation processes and policies.Flags and reports discovered documentation and/or workflow deficiencies against payer and regulatory guidelines to ensure supporting documentation stays current to minimize risk and ensureContributes with focused examination of regulations requiring attention and aides in developing strategies to address these.Acts as a resource, providing professional guidance for department leaders and staff.Acts as a liaison to regulatory/compliance and patient financial services to aide in resolving high risk documentation related issues including patient financial complaints.Required Skills:Working knowledge of documentation auditing processes with an emphasis on procedures and clinical responsibilitiesAble to develop and present complicated materials in a comprehensible manner.Familiar with medical terminology and the patient to admission lifecycle.Capable of working independently and as part of a team; able to take initiative.Positionmayrequire COVID vaccination or medical/religious exemption based on future CMS mandate.Required Experience:High School Diploma required.
Associate degree preferred but not required if commensurate experienceCertification in Health Information Technology preferredMinimum of two or more years experience in Health Information Management required.Must be fully vaccinated for Covid unless approved for a medical or religious exemption.Benefits:Comprehensive benefits package (medical, dental, vision, etc.) for positions of 30 hours or more per week.Childcare reimbursement offered for positions of 20 hours or more per week.Gainshare bonus based on company goals.401k with matching contribution that is fully vested from day 1.Loan relief, tuition reimbursement and scholarship opportunities.
ABOUT ROGERS BEHAVIORAL HEALTHRogers Behavioral Health is a nationally recognized, not-for-profit provider of highly specialized psychiatric care.
Rogers offers evidence-based treatment for children, teens, and adults with OCD and anxiety, addiction, depression and other mood disorders, eating disorders, trauma, and PTSD.
Backed by more than a century of experience, Rogers is leading the way on measurement-based care and use of clinical outcomes.Rogers provides residential care and has three inpatient facilities located in southeastern Wisconsin.
Rogers also offers outpatient services in a growing network of communities across the U.S.The System also includesRogers Behavioral Health Foundation, which supports patient care, programs, and research; andRogers InHealth, an initiative that works to eliminate the stigma of mental health challenges.
For more information, visitrogersbh.Org.
EOE/MFDV