Clinical Documentation Spec

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POST DATE 9/13/2016
END DATE 2/22/2017

HCA Healthcare Snellville, GA

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

JOB DESCRIPTION

Job Code: 08621-9761

Full-time

No Weekends

EASTSIDE is a 310-bed, full-service, acute care medical center with nearly 1,200 employees and 450 affiliated physicians. The hospital is fully accredited by The Joint Commission. EASTSIDE MEDICAL CENTER has been a leader for 31 years in a wide range of state of the art healthcare, including emergency services, neurosurgery, orthopaedics, women s services, neurosciences, oncology, cardiology and behavioral health.

POSITION RESPONSIBILITIES:

* 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.



QUALIFICATIONS:

* 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


SPECIAL SKILLS REQUIRED:

* Must possess advanced communication and interpersonal skills with all levels of internal and external customers.

* Must demonstrate excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills.

* Must be proficient in organization and planning.

* Must possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching.

* Must demonstrate working knowledge of quality improvement theory and practice.

* Must have working knowledge of DRGs and medical necessity criteria.

* Knowledgeable of Federal, State, and other payers regulations, requirements, and criteria.


DEGREE OF SUPERVISION REQUIRED: Minimal, must be able to work independently

EMPLOYEES SUPERVISED: NA

Last Edited: 12/20/2016