Responsible for day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the Clinical Documentation Program. Ensures overall quality and completeness of clinical documentation for Medicare, Medicaid or other payers for inpatient population. Supports goal of ensuring that clinical severity is captured for the level of service rendered to all patients. Capability to analyze clinical status of patient, current treatment plan, and past medical history to identify potential gaps in Provider documentation. Able to work closely with Coding staff to assure documentation of discharge diagnoses and co-existing comorbidities are a complete and accurate reflection of the patient’s clinical status and care. Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
Two (2) years experience in Clinical field, Coding, Care Management or any combination of education, training and/or experience which demonstrates competence as described in Special Skills and Position Summary; Registered Nurse or Clinical Degree in related field preferred.
Bachelors Degree preferred
Must have one of the following – RN, RHIA, CCS
Special Skills: Strong Clinical background. Exceptional problem-solving, time management and organizational skills. Ability to work independently and communicate effectively and efficiently with Medical Staff and Healthcare Team. Strong familiarity with medical practices, especially disease management and health and wellness programs. Works with the Medical Staff and Documentation Team members to provide physician and staff education related to clinical documentation. Have extensive knowledge of medical terminology and regulatory agency requirements. Possess exceptional written and verbal communication skills in order to establish and maintain successful working relationships with all levels of staff. Possess tact, initiative and confidence to meet the essential functions of the position.
Physical Requirements: Light
While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert up to 15 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or up to 5 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.