Documentation Clerk jobs in New Haven, CT

MAIN FUNCTION:  The CDI specialist is a clinically knowledgeable professional who is proficient in analyzing and interpreting medical record documentation and capable of tracking and trending their CDI program goals and objectives.  This professional possesses knowledge of healthcare and coding regulations, as well as anatomy, physiology, pharmacology and pathophysiology.  Further possesses the valuable ability to engage physicians in dialogue and educational efforts regarding how appropriate clinical documentation benefits patient outcomes and the overall well-being of the healthcare system.

ESSENTIAL RESPONSIBILITIES & DUTIES:

• Able to identify the principal diagnosis and relevant secondary diagnosis.
• Able to identify needed documentation clarification and ensure response to both written and verbal queries.
• Identifies opportunities for teaching and engages physicians/LIPS in that process Is able to provide both group and individual education to physicians and staff.
• Collaborates with all other hospital disciplines to ensure the medical record accurately reflects the condition of the entire hospital admission. 
• Able to assign the principal procedure for surgical cases.

EDUCATION: RN, Minimum Bachelor’s degree preferred

EXPERIENCE: Minimum six months in same or similar position.  Computer literacy and the ability to type are required.

*This is position is NOT remote. Must be local and onsite.*