Clinical documentation specialist [h1.location_city]

Job Description

Responsibilities

POSITION SUMMARY :

Responsible for improving the overall quality and completeness of clinical documentation. Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for STHS. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality. Educates all members of the health care team on an ongoing basis.

Qualifications

QUALIFICATIONS :

1. Excellent written and verbal communication skills required.

2. Excellent critical thinking skills required and must be detail oriented.

3. Knowledge of age-specific needs and elements of disease process and related procedures required. Strong broad based clinical knowledge and understanding of pathology / physiology of disease processes.

4. Ability to work independently in a time-oriented environment is essential.

5. Working knowledge of Medicare reimbursement system and coding structures preferred, by not required.

6. Computer literacy essential.

7. Must demonstrate commitment and adherence to STHS’s Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer.

EDUCATION / LICENSURE :

1. Associate, Bachelor or Master’s Degree in Nursing or Healthcare Related Field; Advanced degree such as International MD degree acceptable.

2. Minimum of 3-5 years clinical experience in an acute care or direct patient care setting; Critical Care, Medical / Surgical or Emergency Department nursing preferred.

3. Must be able to travel between facilities as needed.