Clinical Documentation Spec 9/13/2016
JOB DESCRIPTIONAPPLY Job Code: 08621-9761
* 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