Clinical Documentation Specialist
6 days ago
Job Summary:
We are seeking a skilled Clinical Documentation Specialist to join our team at Adventist Health. As a key member of our healthcare team, you will be responsible for reviewing, evaluating, and assessing medical records of patients to ensure the overall quality and completeness of clinical documentation.
Key Responsibilities:
- Evaluate and assess medical records of patients to ensure accuracy and completeness of clinical documentation.
- Analyze and interpret medical records and clinical documentation to formulate appropriate physician queries.
- Perform follow-up on incomplete physician queries to obtain answers while the patient is still in-house.
- Update working DRG assignments as documentation supports or physician query answers support a change in DRG assignment.
- Review quality of medical records and communicate conflicts to the department lead for resolution.
- Stay up-to-date on regulatory changes related to documentation, coding, and communicate these changes to staff.
- Act as a liaison between medical staff and coding department to ensure accurate clinical information in medical records.
- Perform other job-related duties as assigned.
Requirements:
- Associate's/Technical Degree or equivalent combination of education/related experience: Required
- Bachelor's Degree: Preferred
- Three years' clinical experience: Required
- Two years' clinical documentation experience: Required
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required
- Current licensed RN, medical provider, or equivalent: Required
Organizational Requirements:
Adventist Health is committed to the safety and well-being of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu, COVID-19 vaccine, etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.
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