Clinical Documentation Spec

Summary

• This position is responsible for facilitating timely and accurate physician documentation in the medical record through concurrent chart review. Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders is key to the success of this position. This position is also responsible for ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines. Understand and utilization of ICD-10-CM and PCS coding assignment and follow Official Coding Guidelines.

Job Requirements

• Education Required: Graduate of an approved nursing program Preferred: Bachelor's Degree in Nursing
• Experience Required: 3 year’s acute care experience, 5 years preferred Preferred: Preferred experience in (ED, ICU, Neuro or Stepdown)
• Skills Ability to apply coding guidelines when reviewing documentation in the medical record. Ability to perform computer data entry. Ability to work with others and communicate effectively.
• Licensure/Certification/Registration Required: Registered Nursing License Preferred: CCDS or CDIP

Additional Information Job Benefits & Perks!

• Tuition reimbursement up to $1200 per year
• Additional Educational Assistance programs available
• Health/Dental/Vision
• Retirement with employer match
• 20% tuition discount on most classes at Cox College
• On-site Daycare with extended hours, holidays and weekends
• Employee Discount at CoxHealth Fitness Centers
• Pharmacy delivery to your unit
• On-site Employee Health services
• Opportunity to earn referral bonuses of up to $5,000 per hire for certain positions
• 1906 Employee Store
• Cafeteria discount