Three positions in AZ, IL and MA.
The Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation. The position:
- Performs concurrent record reviews on all selected admissions and documents findings.
- Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, care management, nursing staff, other patient care givers and medical record coding staff.
- Serves as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality and final code assignment.
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
- Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals.
- Reports concurrent chart review and query outcomes to hospital departments and committees at designated intervals.
- Maintains accurate records of review activities to comply with departmental and regulatory agency guidelines.
- Understands and complies with policies and procedures related to confidentiality of medical records.
- Identifies opportunities for intradepartmental and interdepartmental operational improvements.
- Performs monthly closed chart reviews and serves on the Chart Documentation Committee.
- Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities.
Requirements:
- Graduate of an approved Health Information Technology/Management program with credentials of RHIA, RHIA eligible, RHIT, RHIT eligible, CCS, CCS-P and/or graduate from an accredited nursing program with LPN or RN licensure.
- Two years of experience in an acute care setting. Knowledge of care delivery documentation systems and related medical records documents.
- Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
- Excellent written and verbal communication skills, critical thinking skills and interpersonal skills to build effective partnering relationships with physicians, care management team, nursing staff, coding staff and hospital staff.
