Clinical Documentation Specialist, Full-time, Days
Location:
Normal
Department:
Health Info Management
Status:
Full-Time
Job ID:
1919
Date Posted:
7/13/2009
Description
The Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on selected admissions and documents findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management staff, nursing staff, other patient caregivers, and HIM coding staff. Serves as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve the quality of documentation and help ensure accurate HIM code/DRG assignment. Monitors, evaluates, and reports the effectiveness of concurrent chart review and query outcomes. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
Required Skills
•Bachelors or Associate degree with RHIA, RHIT, or CCS •Minimum three years acute care coding experience or three years acute care clinical experience •Knowledge of documentation for coding/billing compliance and reimbursement •Knowledge of revenue cycle •Strong verbal and written communication skills •Critical thinking and analytical skills
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