Omega Healthcare Solutions

The Clinical Documentation Specialist coordinates and maintains all elements of the Clinical Documentation Improvement Program, focusing on staff and physician education to ensure high-quality documentation supporting compliance and accurate representation of patient care. This role involves meeting CDI program objectives, ensuring timely and accurate documentation for outcome measurement, analyzing data, and collaborating proficiently with coding professionals.

The Inpatient Coder reviews medical records to perform accurate coding for all diagnoses, procedures, and DRGs, ensuring proper codes are used for reimbursement, research, and quality evaluation. Responsibilities include abstracting, coding, and sequencing clinical information from various medical records while maintaining patient confidentiality.

The Coder Physician reviews medical records to perform accurate coding for all diagnoses, procedures, DRG/APC, and charge codes, ensuring proper sequencing for reimbursement and compliance. Responsibilities include abstracting and interpreting clinical information from various record types and entering codes into multiple software systems while maintaining patient confidentiality.

Summary/Objective Under limited supervision the Coder HCC reviews medical records and performs coding on all diagnoses, procedures, DRG/APC and charge codes. The Coder HCC uses the most accurate codes for reimbursement purposes, research, epidemiology, statistical analysis outcom...