Clinical Documentation Specialist

Singing River Health System • Remote Alabama, SC

20h • Remote

About The Position

The Clinical Documentation Specialist improves the overall quality and completeness of clinical documentation; facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the complexity and severity of illness for a complete and accurate level of service rendered to patients. He/She analyzes the clinical status of patients, current treatment plans and past medical history to identify potential gaps in clinical documentation. The Clinical Documentation Specialist educates and serves as a clinical liaison to nursing staff and other clinicians on compliant documentation and accurate coding. He/She reconciles DRG differences between the Coding staff and Clinical Documentation Specialist; and monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations.

Requirements

• High School graduate or equivalent required.
• If Registered Nurse, must be a graduate from NLN School of Nursing; Bachelor of Science in Nursing required.
• If Registered Nurse (RN), must hold current applicable license to practice in Mississippi.
• If not a Registered Nurse, must be certified by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) as a: Registered Health Information Administrator, Registered Health Information Technician, Certified Code Specialist, or Certified Inpatient Coder.
• Must complete all requirements (including continuing education) to maintain certification.
• Must have de-escalation training completed by the end of position orientation (90 days); must have appropriate level of de-escalation training.
• A Registered Nurse must have a minimum of two (2) years’ nursing experience in an acute-care facility.
• Coders must have a minimum of two (2) years’ experience in ICD-9 CM and experience utilizing ICD-10 CM and ICD-10 PCS in an inpatient setting.
• Must have working knowledge of the AHA Coding Clinic.
• An understanding of the MS-DRG payment system is required.
• Must demonstrate keen mental faculties/assessment and decision making abilities.
• Must demonstrate superior communication/speaking/enunciation skills to receive and give information in person and by telephone.
• Must demonstrate strong written and verbal communication skills.
• Must possess emotional stability conducive to dealing with high stress levels.
• Must demonstrate ability to work under pressure and meet deadlines.
• Attention to detail and the ability to multi-task in complex situations is required.
• Must have the ability to maintain collaborative and respectable working relationships throughout SRHS and other organizations.
• Must possess superior customer service skills and professional etiquette.
• Must possess proficient knowledge and ability to use a computer (must be keyboard proficient) and other office technology (i.e., telephone, fax, etc.), MS Outlook and Word.
• Must possess highly developed organizational, planning and management writing skills.
• Must understand the fundamentals of automated data processing, and be able to quickly gain a detailed understanding of complex computerized and non-computerized information.

Nice To Haves

• Current Mississippi RN license preferred.
• CCDS preferred.
• An understanding of APR-DRG’s preferred.

Responsibilities

• Improves the overall quality and completeness of clinical documentation.
• Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the complexity and severity of illness for a complete and accurate level of service rendered to patients.
• Analyzes the clinical status of patients, current treatment plans and past medical history to identify potential gaps in clinical documentation.
• Educates and serves as a clinical liaison to nursing staff and other clinicians on compliant documentation and accurate coding.
• Reconciles DRG differences between the Coding staff and Clinical Documentation Specialist.
• Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations.

Benefits

• best-of-industry benefits
• scheduling options
• professional pathways

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED