Health Information Management Clinical Documentation Specialist

6 days ago

Sacramento California, United States Northern California Behavioral Health System Full time
Job Summary

We are seeking a highly skilled Clinical Documentation Specialist to join our Health Information Management team at Northern California Behavioral Health System. This role is responsible for supporting the Health Information Management Department through various clerical, technical, and related support services.

Key Responsibilities
  • Abstract and summarize patient information from the medical record to create hospital discharge summaries.
  • Ensure medical record compliance by self-documentation attestation.
  • Prepare and send all documentation to physicians for review and approval via facility-specific procedures.
  • Comply with hospital policies, including those relating to HIPAA and The Joint Commission.
  • This is an on-site position.
RequirementsKnowledge and Experience
  • High school diploma or equivalent required. Bachelor's degree in a related healthcare field required.
  • Medical school graduate preferred.
  • 2 years of Health Information/Healthcare experience, experience in psychiatry required.
  • Knowledge of medical terminology, with specific familiarity with psychiatric terminology preferred.
  • Advanced proficiency in operating medical record software preferred.
  • One year of required experience in providing accurate and complete medical record documentation.
  • Demonstrated knowledge of patient privacy (HIPAA) relative to maintaining medical records required.
Skills and Abilities
  • Maintains confidentiality of patient information at all times.
  • Sensitivity to and willingness to interact with persons of various social, cultural, economic, and educational backgrounds.
  • Proficiency with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel, and PowerPoint).
  • Strong organizational skills with the ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.
  • Strong written and verbal communication skills.
  • Strong interpersonal skills. Ability to work with people with a variety of backgrounds and educational levels.
  • Ability to work independently and as part of a team.
  • Good judgment, problem-solving, and decision-making skills.
  • Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.
  • Ability to work in a fast-paced, expanding organization.
Physical Requirements
  • Use standard office equipment and access, input, and retrieve information from a computer.
  • Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.
  • Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.
  • Frequent bending, squatting, kneeling, climbing with the use of a step stool, and twisting.
  • Lift and carry up to 20 pounds.
  • Sit or stand for minimum periods of one hour at a time. Come and go from the work area repeatedly throughout the day.
  • Give and follow verbal and written instructions with attention to detail and accuracy.
  • Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.
  • Vision: see details of objects at close range.
  • Coordinate multiple tasks simultaneously.

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