Clinical Documentation Specialist - Health Information Management - Full-Time
Clinical Documentation Specialist - Health Information Management - Full-Time
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$ 30 - 44
1 Vacancy
Job Description
The Clinical Documentation Specialist is responsible for assisting in the improvement of the overall quality and completeness of providerbased clinical documentation in the medical record. The Specialist will conduct ongoing concurrent analyses of clinical information in collaboration with physicians nursing staff and other patient caregivers to accurately reflect the severity of illness of the patient as well as the level of services rendered.
Requirements:
- Twoyear associate degree or fouryear bachelors degree in nursing.
- Applicable clinical or professional certifications and licenses such as RHIT RHIA CCS CPC CCDS CDIP RN LPN required.
- Minimum of two years related work experience in an acute care setting.
- Clinical nursing Health Information Management and Clinical Documentation experience preferred.
- Proficiency in a medical record review.
Responsibilities:
- Facilitates appropriate clinical documentation to support correct diagnosis coding and ensure the level of service rendered to all patients is documented.
- Communicates with physicians nurse practitioners case managers coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment decisionmaking and medical documentation.
- Assigns a working DRG and severity level using coding rules and guidelines with followup reviews as required by length of stay prior to discharge.
- Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation.
- Queries physicians on a concurrent basis monitors the query response from the physician documents the physician response in 3M and closes out the analysts review if prior to discharge.
- Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis comorbidities present on admission (POA) quality core measures and patient safety indicators.
- Works with Physician Advisor and CDI Manager to resolve documentation discrepancies and clinical disparities.
- Monitors and track trends in clinical documentation identifying areas for improvement and ensuring compliance with internal and external standards.
- Any other duties as assigned by Womans Hospital.
Schedule:
Monday Friday / Hybrid Schedule
8:00 AM 4:30 PM
Pay Range:
Salary/Exempt
$30.00 $44.00
A Work Experience with Purpose
Womans is one of the largest specialty hospitals for women and infants in the United States. We are recognized throughout the country for our innovative programs and we pride ourselves in surpassing the expectations of those we serve. Providing exceptional patient care and creating exceptional patient experiences are at the center of what we do at Womans. Our team consistently exceeds state and national benchmarks for patient satisfaction.
Our employees organizational culture mission vision values and benefits make Womans a best place to work. In fact for the17th year in a row Womans has been recognized as aBest Place to Work by Modern Healthcare making us the only healthcare organization to earn the distinction every year since the programs inception. We are proud of the level of care our staff provides to our patients and each other.
If you have any questions or would like to connect with one of our recruiters directly please email.
We are an equal opportunity employer and value diversity and inclusion at Womans Hospital. We do not discriminate on the basis of race color religion sex sexual orientation age disability genetic information veteran status national origin gender identity and/or expression marital status or any other characteristic protected by federal state or local law.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
