CLINICAL DOCUMENTATION SPECIALIST

Company Description

Healthcare

Job Description

CLINICAL DOCUMENTATION SPECIALIST

Hickory North Carolina 

Exp 2-5 yrs

Deg Bachelors

Relo

Bonus

Occasional Travel

Job Description

1. Collaborate with physician, physician extender, nurse, case manager, and Health Information Management coder to identify areas for improved physician documentation.

2.   Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings on worksheets, denoting all key information utilized in the tracing process.

3.   When a need to clarify documentation in the records is identified, individual must utilize assertive communication skills to guide physician, case manager, or other healthcare professionals to make changes as appropriate to clarify documentation.  Must work collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality in compliance with all guidelines and requirements.  Follow thru to obtain response to physician queries.

4.   Utilize monitoring tools to track the progress, monitoring reports and data.  Communicate findings with appropriate management staff.  Able to identify areas of focus through report analysis.

5.   Assist in the development of physician query response reports.  Provides education and in-services as necessary to physicians and ancillary staff.

Qualifications

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Must possess a current, valid RN or LPN license or an RHIA, RHIT, or CCS credential.

Minimum of 3 years clinical OR inpatient coding experience in an acute care setting required; 5 years experience strongly preferred.

Familiarity with coding concepts and coding software desired. Knowledge of care delivery documentation systems, related medical record documents, age-specific needs, elements of disease processes and related procedures. Strong broad-based clinical knowledge, understanding of pathology/physiology of disease processes. Excellent written/verbal communication skills, critical thinking skills, interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff, and health information management coding staff. Ability to work independently in a time-sensitive environment, ability to stand and walk for periods of time is required in the performance of job responsibilities. Computer literacy and familiarity with the operation of basic office equipment. Assertive personality traits to facilitate ongoing physician communication. Working knowledge of Medicare reimbursement system and coding structures/national coding guidelines.

Qualifications

Additional Information