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Clinical Documentation Integrity Coordinator, FT, Days

Prisma Health
United States, South Carolina, Columbia
May 14, 2025
Inspire health. Serve with compassion. Be the difference. Job Summary To facilitate concurrent chart review in order to monitor effectiveness of documentation and physician queries. To participate with third party audit reviews and to perform closed chart reviews to determine and/or implement improvements. To assist with on-going education for physicians and other care providers. To collaborate with coders, case management and physicians to ensure accurate DRG assignment based on documentation. To serve as a preceptor, education resource, and escalation point for the clinical documentation specialists. Accountabilities Performs concurrent documentation review of selected patient health records to clarify conditions, diagnoses, and procedures when conflicting or inadequate documentation is suspected. Provides formal and point-of-care clinical documentation education sessions for physicians, nurses, and allied health professionals for complete and accurate documentation. Serves as a preceptor, education resource and escalation point for clinical documentation specialists. Collaborates with providers, coders, care givers to support the level of severity and clinical picture of patients and ensure accurate Diagnosis-Related Group (DRG) assignment based on documentation. Monitors and evaluates effectiveness of concurrent chart reviews and physician query outcomes. Performs monthly closed chart reviews as part of retrospective auditing and to define improvements opportunities. Participates in third party audit reviews and assists with implementation of recommendations. Assists in overall quality, timeliness, and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes. Performs other duties as assigned. Supervisory/Management Responsibilities This is a non-management job that will report to a supervisor, manager, director or executive. Minimum Education Bachelor's degree in Nursing, Physical Therapy, Respiratory Therapy, Health Information Management, or related field. Minimum Experience Five(5) years experience in adult medical/surgical/critical care/ER/PACU nursing, physical therapy, respiratory therapy, clinical documentation improvement, or inpatient coding and two(2) years experience as clinical documentation specialist. Work experience may NOT substitute for education requirement. Required Certifications/Registrations/Licenses Currently licensed or eligible to be licensed as a Registered Nurse (RN) in South Carolina by the South Carolina Board of Nursing, currently licensed as a Physical Therapist (PT) by the South Carolina Board of Physical Therapy, currently registered as a Registered Respiratory Therapist (RRT) by the National Board for Respiratory Care (NBRC), currently credentialed as a Registered Health Information Technician (RHIT) by the American Health Information Management Association (AHIMA), currently credentialed as a Registered Health Information Administrator (RHIA) by AHIMA, or currently credentialed as a Certified Coding Specialist (CCS) by AHIMA. In addition, must also be Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Improvement Specialists (ACDIS) or Certified Documentation Improvement Practitioner (CDIP) by the American Health Information Management Association (AHIMA); Basic Life Support (BLS) required. Employees hired prior to June, 2016 may be a Certified Respiratory Therapist. Other Required Experience Proficiency in comprehension of clinical disease process and treatment and regulatory documentation requirements. Excellent oral and written communication skills. Demonstrated analytical/critical thinking skills. Excellent observation, analytical/critical thinking and problem solving skills. Ability to handle stressful situations while remaining tactful. Computer proficiency. Work Shift Day (United States of America) Location Corporate Facility 7001 Corporate Department 70017540 Clinical Documentation Integrity Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.