Clinical Documentation Improvement Specialist
InnovaCareJob Summary:
A Clinical Documentation Improvement Specialist is responsible for using their clinical and technical knowledge and their knowledge of medical terminology and procedures to evaluate a patient's medical record for accuracy. It’s important as part of this role to collect and update information about a patient after an appointment, including details and information about medical history and previous treatments and appointments.
Essential Job Functions:
Reviews medical records and documents for a complete analysis of the patient's status
Ensures the accuracy of all medical documentation and establishing compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other government regulations.
Communicates with other departments to correct missing or incorrect data and information.
Interprets clinical data and making sure that it's both accurate and completes by sorting and filing the required documents.
Stores medical documentation and validates diagnosis codes to represent different medical disorders, diseases, and symptoms.
Trains new staff members on different medical record-keeping policies, instructs them on how to file medical documentation, and secure it properly.
Enters document queries into a database and tracks reimbursements from insurance.
Minimum Required Education, Experience & Skills
Associate or undergraduate degree in related field.
Interpersonal skills
Computer literacy with word processing and spreadsheet software
Ability to apply technical principles and concepts
Organized and able to work independently