Clinical Documentation Specialist
3 weeks ago
Job Description
ECU Health
About ECU Health Medical Center
ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people.
Position Summary
* Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record. Accurately identifies physician query opportunities.
* Stays current with and conducts on-going clinical documentation management program education.
* Collaborates effectively with departmental/program staff to achieve goals and objectives.
* Demonstrates acceptable level of value based behaviors
Responsibilities
* Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
* Records appropriate admission status, working DRG & LOS info in CDI Tracking tool.
* Comprehensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans and accurately identifies physician query opportunities.
* Reviews medical record every 24-48 hours as appropriate for changes in clinical condition or to ensure issues discussed and clarified with the physician have been documented in patient's chart.
* Updates CDI Tracking tool to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate for intradepartmental communication.
* Effectively communicates with physicians and other members of the interdisciplinary team to clarify potential documentation opportunities.
Minimum Requirements
* ADN, BSN, MD or equivalent is required
* At least 5 years experience providing direct patient care to acute and chronically ill patients in inpatient settings, critical care, ED or strong med-surg experience preferred.
* Demonstration of organizational, critical thinking and communication skills.
* Prefer ED/Critical care or case management; or inpatient acute care (referral hospital); strong critical thinking skills; strong interpersonal skills; strong clinical knowledge base.
* 3 years recent CDI experience preferred.
* Coding, Case Management and/or Utilization Review experience preferred.
General Statement
It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.
Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.
We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant's qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.
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