Clinical Documentation Specialist

4 weeks ago


Harlingen, Texas, United States Harlingen Medical Center Full time
Job Summary

Clinical Documentation Specialist is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided. This role will work closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings. Additional duties as provided.

Responsibilities

Conduct clinically based concurrent and retrospective reviews of inpatient medical records
Evaluate clinical documentation for quality of care outcomes and reimbursement compliance
Work closely with medical staff to facilitate appropriate clinical documentation of patient care
Conduct documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions
Document findings and provide additional support as needed

Requirements

Medical Graduate, PA or Nursing Graduate
Minimum of 3 years clinical experience in an acute care setting
Knowledge of care delivery documentation systems and related medical record documents
Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes
Excellent written and verbal communication skills
Excellent critical thinking skills
Ability to work independently in a time-oriented environment
Computer literacy and familiarity with the operation of basic office equipment

Preferred Qualifications

Working knowledge of Medicare reimbursement system and coding structures

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