Sr. Coding & Clinical Documentation Specialist

About This Role

This role is responsible for conducting in-depth reviews of clinical documentation to ensure compliance with coding guidelines, regulatory requirements, and accuracy for Temple University Health System. The specialist will provide coding expertise, identify compliance issues, and facilitate improvement in medical record documentation quality.

Responsibilities

• Conduct in-depth reviews of clinical documentation to ensure compliance with coding guidelines
• Ensure compliance with regulatory requirements, clinical validation, and overall coding accuracy
• Provide coding expertise and guidance to physicians, nurses, and other healthcare professionals
• Identify and address coding-related compliance issues
• Facilitate improvement in overall quality, completeness, and accuracy of medical record documentation
• Stay up to date with coding guidelines, regulations, and industry changes
• Serve as an expert for CDI and Coding teams on topics such as coding compliance, clinical validation, PSIs, HACs and Vizient variables
• Communicate and collaborate with CDI and Coding Leadership teams to provide feedback on medical chart reviews

Requirements

• 5 years experience in Coding and/or CDI for inpatient records
• Expert knowledge of ICD, CPT, DRG, and APC coding and classification

Qualifications

• Bachelor's Degree Bachelor of Science in Nursing or related field or Combination of relevant education and experience
• 5 years experience in Coding and/or CDI for inpatient records

Nice to Have

• Experience with EPIC

Skills

* Required skills