Clinical Documentation Specialist

CoxHealth • Springfield, MO

20h • Onsite

About The Position

This position is responsible for facilitating timely and accurate physician documentation in the medical record through concurrent chart review. Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders is key to the success of this position. This role also involves ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines, and understanding and utilization of ICD-10-CM and PCS coding assignment while following Official Coding Guidelines. CoxHealth is a leading healthcare system serving 25 counties across southwest Missouri and northern Arkansas, comprising six hospitals, 5 ERs, and over 80 clinics, with more than 14,000 employees. The organization has received numerous accolades for workplace excellence, including being named one of Modern Healthcare’s Best Places to work five times, and recognized by Newsweek and Forbes for being a great workplace for various groups. CoxHealth's mission is to improve the health of the communities they serve, with a vision to be the best for those who need them, guided by values of safety, compassion, respect, and integrity.

Requirements

• Graduate of an approved nursing program
• 3 year’s acute care experience
• Ability to apply coding guidelines when reviewing documentation in the medical record.
• Ability to perform computer data entry.
• Ability to work with others and communicate effectively.
• Registered Nursing License

Nice To Haves

• Bachelor's Degree in Nursing
• 5 years acute care experience
• Experience in ED, ICU, Neuro or Stepdown
• CCDS or CDIP certification

Responsibilities

• Facilitating timely and accurate physician documentation in the medical record through concurrent chart review.
• Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders.
• Ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines.
• Understand and utilization of ICD-10-CM and PCS coding assignment and follow Official Coding Guidelines.

Benefits

• Medical
• Vision
• Dental
• Retirement with Employer Match

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 101-250 employees