Clinical Documentation Spec 9/13/2016

HCA Healthcare Snellville, GA

Company
HCA Healthcare
Job Classification
Full Time
Company Ref #
08621-9761
AJE Ref #
576162464
Location
Snellville, GA
Experience
Mid-Career (2 - 15 years)
Job Type
Regular
Education
Bachelors Degree

JOB DESCRIPTION

APPLY
Job Code: 08621-9761

Full-time

No Weekends

* Analyzes inpatient records for status of the patient, current treatment plan and past medical history to identify potential gaps in physician documentation.

* Based on the review the Clinical Documentation specialists may query the physician verbally and/ or in writing to assure the appropriate documentation is documented in the body of the medical record, to capture the patient s severity of illness.

* Able to communicate with attending physicians and residents to validate observations

Able to work closely with the HIM coding staff to assure documentation of discharge diagnosis and any co-existing, co-morbidities that are a complete reflection of the patient s clinical status and care

* Minimum of 2 years hospital experience required.

* Recent coding experience,

* Utilization Review or Case Management Experience preferred

* Bachelor s degree in healthcare related field preferred

* RN or RHIA preferred

Last Edited: 11/18/2016