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The role of the CDI Annotator includes the following:
- Ability to identify cases where clarifications for diagnoses and procedures are either absent, not stated in appropriate terminology, or are not appropriately recorded.
- Use custom Nuance tools; review, verify, edit, add and correct extracted health care clarification opportunties from information in medical record reports, discharge summaries, emergency room reports, and consultation notes, in accordance with developed guidelines and standards for fact extraction.
- Maintain a strong background in APR-DRG's, MS-DRG's, ICD-9 codes, ICD-10 codes, Coding Guidelines and Coding Clinics.
- Ability to comprehend and process complexity of medical conditions and identify same within the medical record.
- Maintain effective clarification process to ensure a complete medical record that reflects accurate severity of illness and facilitate accuracy of coding and DRG assignment.
- Serve as a clinical and coding resource for both internal and external customers.
- Perform Quality Assurance tasks of extracted facts and medical coding.
- Work in tandem with Clinical Staff including CDI RN and Chief Medical Officer.
- Comply with company procedures and work processes for the work unit, and propose enhancements to these.
- Participate in research that contribute to product advancement as needed.
- Contribute to and participate in mandated training programs
Maintain clinical and coding knowledge, skills, and active certification through attending continuing education activities, reviewing pertinent literature, and participating in other credentialing educational forums. Qualifications:
- 5 + years’ experience as an Inpatient Coder, DRG Validator or Clinical Documentation Improvement Specialist required
- Proven verbal and written communication skills, including presenting and/ or facilitating training sessions
- Demonstrated experience establishing and managing strong relationships with physicians and clinicians.
- Comfort working in a fast-paced, deadline driven environment with a cross functional team of product managers, interface designers, consultants, delivery staff, and engineers as well as clients
- Superior analytical abilities: ability to draw insight from findings and understand the root cause of annotation issues
- Demonstrated experience and motivation to provide excellent customer service
- Team-oriented but also highly self-sufficient, diligent and self-motivated
- ICD-10 coding knowledge desired
- Experience with SNOMED CT coding highly desirable *
- Possess knowledge of work flow processes and clinical systems used in hospitals
- Proven organizational skills and ability to balance multiple projects
- RHIA, RHIT , CCS , or BSN and CCDS, (? add CDIP) credentials preferred
- Degree in HIM, business, health care administration or other health care-related field a plus
- Experience working with or in a clinical atmosphere including physician practice or hospital setting preferred.
- Experience with Microsoft Office products including Word and Excel
- Bachelor’s Degree in HIM, Healthcare Administration or other Healthcare related field; Prefer RHIA, RHIT, or CCS credentials
We offer a competitive compensation package; including stock options, employee stock purchase plan, 401(k), full health and welfare benefits and a casual yet technically challenging work environment. Join our dynamic, entrepreneurial team and become part of our fast growing track of continuing success. Nuance is an Equal Opportunity Employer. Overview:
Nuance Healthcare, a division of Nuance Communications, is the market leader in providing clinical understanding solutions that accurately capture and transform the patient story into meaningful, actionable information. Thousands of hospitals, providers and payers worldwide trust Nuance speech-enabled clinical documentation and analytics solutions to facilitate smarter, more efficient decisions across the healthcare enterprise. Nuance Healthcare has been recognized as “Best-in-KLAS” 2004-2011 for Speech Recognition.