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Clinical Documentation Specialist

2 months ago

Davenport, Iowa, United States GENESIS Health System Full time
Job Summary

We are seeking a highly skilled Clinical Documentation Specialist to join our team at GENESIS Health System. As a Clinical Documentation Specialist, you will play a critical role in ensuring the accuracy and completeness of patient medical records.

Key Responsibilities
  • Utilize advanced clinical and coding expertise to review and improve the quality of clinical documentation.
  • Collaborate with healthcare teams to ensure accurate and complete medical records.
  • Develop and deliver education to healthcare providers on clinical documentation best practices.
  • Conduct concurrent reviews of patient health records to address legibility, clarity, and completeness of clinical documentation.
  • Formulate compliant clarifications/queries following GENESIS Health System's documentation integrity procedures.
  • Interact with healthcare teams to ensure compliant documentation requirements are met.
  • Codes all relevant, appropriate, and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
  • Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care.
  • Resolves all discrepancies in a courteous manner.
Requirements
  • Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or an Advanced degree in nursing (NP/APN) or Physician Assistant.
  • Preferred certification or licensure includes: Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Professional (CDIP).
  • Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), or as an inpatient coder preferred.
  • Excellent communication (verbal and written), interpersonal, collaboration, and relationship-building skills.
  • Strong critical thinking skills and ability to integrate knowledge.
  • Prioritization and organizational skills required.
  • Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
  • Data entry skills and typing skills at minimum 30 wpm.
  • Must be comfortable operating independently and in a collaborative environment.
  • Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of GENESIS Health System.
Working Conditions

The Clinical Documentation Specialist will work in a fast-paced environment with frequent interruptions and must be able to concentrate and read for long periods of time. The position requires the ability to work independently and in a collaborative environment.