Senior Clinical Documentation Specialist, PRN

Vanderbilt University Medical Center•Nashville, TN

3d•Onsite

About The Position

Ensures capture of discharge diagnosis and procedures independently. Documents the patient's clinical status and care provided. Performs concurrent review of patient records for documentation to support assignment of clinical codes.

Requirements

LIC-Registered Nurse - Licensure-Others
Relevant Work Experience
3 years
Graduate of an approved discipline specific program

Nice To Haves

Written Communication (Novice): Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos and documentation. Demonstrates an understanding of effective composition, such as having first line in a paragraph state the subject.
Verbal Communication (Novice): Ability to enunciate clearly, using appropriate voice control and body language. Effectively transmits technical and business ideas and information to others. Listens carefully to ascertain points being made before trying to be understood.
Medical Coding (Intermediate): The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
Critical Thinking (Novice): The objective analysis and evaluation of an issue in order to form a judgment.
Relationship Management: Manages internal and external organizational relationships with clients, vendors, partners and staff.

Responsibilities

Performs assessment of patient records to evaluate documentation for accuracy, legibility and completeness.
Works with coding staff to ensure documentation of discharge diagnoses, including any coexisting co-morbidities, and procedures are complete.
Communicates with providers regarding missing, unclear, or conflicting clinical documentation.
Collaborates with case managers, nursing staff, and other staff on documentation issues and resolves provider queries prior to patient discharge.
Monitors provider documentation queries for timely and compliant response and escalates issues.