Job Summary:
Demonstrates excellent problem-solving, clinical knowledge, and coding knowledge. Facilitates the overall quality, completeness, and accuracy of clinical documentation in patient medical records on a concurrent basis. Works collaboratively with providers, case managers, coders, and other health care team members. As part of a multidisciplinary team, ensures that clinical information in the medical record is present and accurate so that the appropriate clinical severity is captured for the level of service rendered. Serves as a resource and provides guidance, support, education, and training on clinical documentation guidelines. Supports departmental and organizational goals to achieve clinical and operational excellence in relation to Clinical Documentation Improvement efforts.
Education:
Position requires a Bachelor’s Degree in Healthcare or Nursing. Master’s degree in Health Administration or other related master’s degree is preferred but not required.
Registration/Certification/Licensure:
Compact state Registered Nurse (RN) required. Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Specialist (CDIS) preferred.
Experience:
Minimum of 5 years’ experience in an acute care hospital clinical setting required, 3 years of Clinical Documentation Improvement experience preferred. Utilization Review and/or Case Management experience preferred but not required.
Other Requirements:
- Maintains unit-specific and hospital competencies, mandatory learning, and any clinical certifications required in accordance with the Staff Education and Training policy GA-057 and/or any other department requirements.
- Intermediate skill level on the computer: Office Products including Word, Excel, and PowerPoint.
- Demonstrates skills in planning, organizing, and managing multiple functions and complex processes.
- Maintains a fast pace, coordinates and is able to multi-task process of requests, and acknowledgement of data and correspondence.
- Must be able to identify and correct weaknesses in the process and alert leadership in the event of negative results/outcomes.
- Requires understanding of many complex and varying guides, systems, regulations, and tools.
- Utilizes critical thinking skills to manage an ever-evolving process that includes financial, clinical, and medical/legal components.
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