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Clinical Documentation Expert

2 months ago

Huntsville, Alabama, United States American Health Partners Full time
Job Summary

This position is responsible for coordinating, recording, updating, and monitoring all Minimum Data Set (MDS) documentation for each Medicare patient as required by state regulations and other appropriate authorities.

Key Responsibilities
  • Regulate and maintain the MDS/PPS program and completion schedule
  • Develop and coordinate appropriate nursing care plans from MDS/RUG category
  • Analyze assessment data independently for complex patient problems and identify early subtle changes that formulate RUG categories and effect patient care
  • Evaluate effectiveness of nursing care plans; update MDS/RAI process within completion guidelines
  • Promptly respond to all emergency calls with appropriate emergency intervention
  • Provide care to patients including administration of treatments, medications, social and emotional support
  • Other duties as assigned
Requirements
  • Successful completion of required training
  • Handle multiple priorities effectively
  • Independent discretion/decision making
  • Reliable transportation
Preferred Qualifications
  • License/Certification/Education:
    • Completion of a Registered Nursing Program
    • Current State of Tennessee Registered Nursing License
    • CPR Certification
  • Experience:
    • Two (2) years' or more experience required
Company Competencies
  • Respect – We treat people as they want to be treated, showing regard for their rights and privacy
  • Integrity – We emphasize honesty, fairness, and doing the right thing even when no one is watching
  • Teamwork – We work collaboratively to improve processes, resolve problems and reward results
  • Excellence – We hold ourselves to the highest standards, aspiring to zero defects in every task
  • Compassion – We respond to those who need help with sensitivity and a positive attitude
  • Professionalism – We perform our duties with skill, good judgement and politeness
Job Competencies
  • Analytical Thinking: Able to gather and analyze data and reach appropriate conclusion; solves problems in a timely manner. Use logic and reasoning to identify changes in patients' conditions to determine the correct plan of action.
  • Customer and Personal Service: Possess good interpersonal skills while dealing with emotional or difficult situations; respond promptly to customer's needs. Knowledge of principles and processes for providing personal services, including needs assessment; meeting quality standards.
  • Accountability: Accepts responsibility for own decisions, actions and results; able to maintain dependable behavior in times of crisis or complexity.
  • Attendance: Is consistently at work and on time; ensures work responsibilities are covered; returns from lunch and breaks appropriately; arrives at meetings on time; notifies supervisor of pending absences.
  • Communication: Speaks and writes clearly and persuasively; listens and receives clarification.
  • Ethical Behavior: Upholds organizational values and abides by state and federal regulations; maintains confidentiality of HIPAA information; treats others with respect.
  • Initiative: Seeks increased responsibility; sets self-improvement goals related to the organization's objectives.
  • Job and Industry Knowledge: Demonstrates knowledge of the position and industry; seeks additional information.
  • Productivity and Quality of Work: Maintains high level of performance while demonstrating commitment to accuracy and thoroughness.
  • Teamwork: Displays ease working with others; contributes ideas and skills to team; puts success of team above own interests. Communicates with co-workers at all levels to adequately meet the needs of patients.
Scope and Level of Work
  • Complexity: Work assignment is performed within an established framework under general instructions but requires simultaneous coordination of assigned functions or projects in various stages of completion.
  • Decision Making: Exercises judgment and discretion, and is responsible for determining the time, place and sequence of the work performed.
  • Communications: Contacts with the public or employees where explanatory or interpretive information is exchanged, defended, and gathered and discretion and judgment are required within the parameters of the job function.
  • Supervision Received: Performs work with supervisory oversight. Under general supervision, receives assignments and is expected to carry them through to completion with substantial independence. Work is reviewed for adherence to instructions, accuracy, completeness, and conformance to standard practice or precedent. Recurring work clearly covered by guidelines may or may not be reviewed.
Working Conditions
  • Able to lift to 40 pounds
  • Subject to standing, walking, sitting, bending, reaching, kneeling, pushing and pulling
  • Work is typically performed in a standard office environment; well-lit; comfortable temperature-controlled
  • Above-average conversational noise is frequent
  • Position may require flexible hours, unscheduled overtime or occasional week-end work
  • Travel may be required