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Clinical Documentation Specialist

Company: East Cooper Medical Center
Location: Mount Pleasant
Posted on: January 10, 2019

Job Description:

Position Summary

Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Will play a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting quality of care outcomes.

Essential Duties and Responsibilities

Collaborates with physician, physician extender, nurse, case manager and Health Information Management coder to identify areas for improved physician documentation.
Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings on worksheets, denoting all key information utilized in the tracking process.
Clarifies documentation in the records utilizing assertive communication skills to guide physician, case manager, or other healthcare professionals to make changes as appropriate to clarify documentation.
Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality in compliance with all guidelines and requirements.
Responds to physicians queries.
Enters working DRGs into the computerized clinical documentation system.
Utilizes monitoring tools, reports and data to track progress.
Communicates findings with appropriate management staff and/or providers.
Identifies the need for clinical documentation through report analysis.
Assists in the development of physician query response reports.
Provides education and in-services as necessary to physicians and staff.


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Other Qualifications

-- Graduate of an accredited school of nursing, AHIMA accredited school, international medical school

-- Must possess a current RN or LPN license or an RHIA, RHIT or CCS credential

-- Minimum of three years clinical or inpatient coding experience in an acute care setting, required; five years experience, strongly preferred

-- Familiarity with coding concepts and coding software desired.

-- Knowledge of care delivery documentation systems and related medical record documents.

-- Knowledge of age-specific needs and the elements of disease processes and related procedures.

-- Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.

-- Excellent written and verbal communication skills.

-- Excellent critical thinking skills.

-- Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff, and health information systems coding staff.

-- Ability to work independently in a time-sensitive environment.

-- Computer literacy and familiarity with the operation of basic office equipment.

-- Assertive personality traits to facilitate ongoing physician communication.

-- Ability to stand and walk for periods of time is required in the performance of job responsibilities.

-- Working knowledge of Medicare reimbursement system and coding structures/national coding guidelines.

Job: Medical Records
Primary Location: Mount Pleasant, South Carolina
Facility: East Cooper Medical Center
Job Type: Full-time
Shift Type: Days

Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

Keywords: East Cooper Medical Center, Mount Pleasant , Clinical Documentation Specialist, Healthcare , Mount Pleasant, South Carolina

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