Clinical Documentation Specialist
3 weeks ago
* This is not a remote position*
Clinical Documentation professionals review records for coding accuracy, follow-up with physicians and inform medical staff members of updated documentation methods.
Responsibilities:
Facilitates the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation through extensive interaction with physicians, nursing staff, other clinical staff, and HIM staff to ensure that appropriate reimbursement is received for the level of care and service rendered to all patients.
Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes.
Facilitates modifications to clinical documentation
Consistently demonstrates effective skills in information management including use of the Meditech computer system to enter and extract data.
Actively participates in utilization team meetings.
Consistently identifies educational needs of the medical and hospital clinical staff regarding clinical documentation and provides appropriate training.
Communicates effectively and appropriately with physician.
Communicates with HIM staff and resolves discrepancies.
Conducts timely follow up on all cases—especially those with queries.
Consistently and effectively provides support and assistance to Department Directors and Managers related to clinical documentation issues.
Evaluates and recommends items, software, procedures, etc. which would support and/or enhance clinical documentation.
Evaluates the effectiveness of clinical documentation on an ongoing basis, identifies opportunities for improvement and implements process changes as needed.
Consistently demonstrates ability to use word-processing and spreadsheet programs to make effective reports.
Consistently maintains an active personal and professional development program in the field of clinical documentation that includes current knowledge of regulatory requirements and changes, evaluation techniques, and research.
Qualifications:
Education:
Experience:
Has minimum of two years of experience in the acute care setting.
Prefer experience in health information management.
Degrees, Licensure, and/or Certification:
Current Arkansas RN or LPN licensure. RN Licensure preferred.
Knowledge, Skills, and Abilities:
Demonstrates working knowledge of Medicare reimbursement system and coding structures.
Improves professional growth and knowledge of job to maintain efficiency and effectiveness by any of the following means: belonging to professional organizations, attending approved seminars, subscribing to and reading journals and publications pertinent to job activities.
Must be able to read, write, speak and understand English
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