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Clinical Documentation Specialist/Coder

4 months ago

Lafayette Hill, United States Masonic Village at Lafayette Hill Full time
Job DescriptionJob Description

Clinical Documentation Specialist/Coder

** Part Time: 8:00am - 4:00pm, 20 hours per week **

Masonic Villages of Pennsylvania - Lafayette Hill campus - is immediately hiring a Part-Time Clinical Documentation Specialist/Coder.

With over 145 years of providing award-winning care and services across the state of PA, Masonic Villages is driven by our Mission of Love to assists individuals in realizing their potential and enjoying the highest possible quality of life.

Why Choose Masonic Villages:

Each campus is supported by corporate leaders who are fully invested in our Mission of Love and hiring like-minded individuals who are committed to providing heartfelt customer service and contributing to our team environment. When you join our team you can expect:

Benefits/Perks for Full Time & Part Time staff:

  • Industry-leading benefits that start day one such as $0 cost medical coverage option
  • Vacation Time/Flex Time and Paid Holidays
  • Paid Lunch (Paid while you work)

Benefits/Perks for ALL staff:

  • Option for pay in lieu of benefits.
  • Pay on-demand. Access up to $500 of your earned wages in real-time.
  • Tuition and Educational Reimbursement
  • Discounts on meals
  • Free Gym Membership
  • Discounted Grocery gift cards
  • Discounted tickets for movies, theme parks, hotels, and MORE
  • Shoe discounts
  • Cell phone discounts
  • Competitive pay rates to attract the best talent
  • Employer matched Retirement Savings with free financial planning
  • A commitment to growing our leaders, with at least 50% of our leadership positions being filled internally

What You'll Do:

As a Clinical Documentation Specialist/Coder, you will carry out our Mission of Love by providing planning, coordination and direction of health information activities necessary to assure clinical excellence, optimal clinical outcomes, regulatory requirements and service excellence, including resident and employee satisfaction.

Our Clinical Documentation Specialist/Coder is responsible for the following:

  • Initiates, writes and updates policies and procedures and evaluation tools for the Health Information Management Department and makes recommendations for new forms, in-services and policy changes based upon new legislation, update technology and prudent medical records practice.
  • Organizes Health Management Department activities to maximize the efficiency of activities including medical record assembly, record auditing and completion, coding and indexing, filing, record retrieval, and information release. Other activities may include transcription of reports, typing of various forms, including Medicare and Medicaid, and minutes of Health Information Management Committee meetings.
  • Implements systems and procedures related to the maintenance of both active and inactive medical records. Reviews medical records of active Health Care residents soon after admission, monthly, and as needed to assure that proper documentation standards are being followed by all disciplines. Sends notification of deficient documentation to the appropriate person when necessary and provides re-education of documentation standards as necessary.
  • Maintains functional filing systems for the discharged/deceased records, the thinned active records, and the Outpatient Department medical records. Thins documentation from medical records in the Health Care Unit in accordance to Masonic Village policy, state, and federal guidelines. Maintains functional filing systems for the discharged/deceased records, the thinned active records and the Community Health medical records.
  • Implements procedure necessary to maintain statistical and administrative reports.
  • Effectively communicates and coordinates overlapping activities with other departments.
  • Maintains index files to provide the necessary information required to retrieve medical records for the purpose of audit or study of particular diagnostic categories.
  • Assumes responsibility for maintaining current knowledge and skills with respect to facility activities, Health Information Management procedures and technology.
  • Assembles and files records of discharged residents from both Health Care and Personal Care areas in a timely manner in accordance with state and federal regulations and Masonic Village policy.
  • Fulfills requests for medical records information from internal and external requesters, e.g. Business Office, insurance companies, Medicare, legal entities, physicians, hospitals, and licensing departments. Maintains individual Disclosure of Information log in accordance with HIPAA standards.
  • Establishes and maintains collaborative communications with the Director of Nursing and other health care professionals and facility departments.
  • Practices fiscal responsibility in the use of supplies, equipment, and time management. Participates in the budget preparation process for the department.

What You Have:

  • Registered Health Information Administrator (RHIA) preferred.
  • Previous experience in a nursing home environment is preferred.
  • Must be familiar with state and federal regulations and standard Health Information Management policies, procedures, and professional practice standards.
  • Must have experience in the processing of Health Information Management, Utilization Review and Quality Assurance.
  • Must possess the ability to communicate clearly and to write in clear and concise terms in an organized manner.
  • Must possess the ability to type. Familiarity with Word is preferred.
  • Must possess the ability to analyze situations and plan interventions, as well as work effectively with managers, co-workers and subordinates to achieve desired goals.
  • Experience with computer hardware and software and their Health Information Management applications are preferred.
  • Good written, oral, organizational and basic computer skills.
  • Limited travel (10%) to our Warminster, PA campus on a monthly basis.

We are proud to be an equal opportunity employer.