Clinical Documentation Spec
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POST DATE 9/13/2016
END DATE 2/22/2017
JOB DESCRIPTIONJob Code: 08621-9761
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.
* 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
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