CLIN DOC IMPROVEMENT SPECIALIST, CLINICAL DOCUMENTATION IMPR

Description

Location: Main Campus

Department: CLINICAL DOCUMENTATION IMPROVEMENT

Schedule: Full Time, 8 HR Day Shift,

Position Summary

Reviews medical records of inpatients and obtains appropriate physician documentation to support the appropriate severity of illness. Facilitates expected risk of mortality, and complexity of care of the patient thereby improving the overall quality and completeness of the medical record documentation. Educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing and case management. Communicates with physicians on documentation needs to support length of stay, severity and DRG assignment.

Knowledge, Skills & Abilities

• RN or other applicable clinical licensure required.
• Bachelor’s degree strongly preferred.
• Previous experience desired. At least 5 years clinical experience, preferable in multiple clinical areas or in an ICU.
• Strongly prefer experience as a Clinical Documentation Specialist or as part of a Clinical Documentation Improvement Program.
• Demonstrated expertise in management, problem solving, critical thinking, and data management including statistical reporting.
• Knowledge of medical literature, research methodology, health care delivery systems, financial/reimbursement issues, utilization management, and the medical center/medical staff organizations.
• Demonstrated knowledge of coding requirements, DRG assignments, case mix index calculations and severity/mortality profiles.
• Computer skills desirable (must be willing to learn spreadsheet analysis, statistical functions, word processing).
• Ability to understand larger scope of hospital-wide information systems. Excellent written and verbal communication skills including presentation and training skills essential.
• Ability to influence decisions, gain cooperation, and facilitate change with physicians, all levels of management, employees and supervisors of other hospital departments.
• Self -motivated and adaptive to change.
  
  

Working Conditions- Ada Information

Requires considerable standing, mental effort, and pushing.Requires walking from unit to unit carrying laptop. Requires operation of office equipment.Works in a high stress environment.