Clinical Documentation Spec
Cook Children's Medical Center - Fort Worth, TX

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SUMMARY: Utilizes clinical expertise to analyze and evaluate completeness and accuracy of concurrent medical record documentation. Requires experience, knowledge and confidence to create appropriate requests for documentation, and to approach providers regarding queries relating to all types of clinical documentation requirements and concerns. Works independently on the patient care units communicating extensively, working collaboratively and interactively with physicians and other members of the healthcare team to ensure clinical documentation is present, complete, clear and accurately reflects clinical decision making, and captures the appropriate clinical severity for the level of patient care service. Fosters relationships between clinical disciplines. Collaborates with coding team to assure accurate coding, DRG assignment and regulatory compliance. Assists with orientation and education in all phases of the CDI process with all providers and other individuals/groups. Assists in development and maintenance of associated policies and procedures, tracks and trends program compliance to sustain positive outcomes, monitors program success via metrics, and provides feedback and education to appropriate individuals and committees. Maintains current and thorough knowledge and understanding of CDI software, Meditech, Athena, coding schemes, DRG groupers, policies, procedures, regulatory requirements and guidelines.

QUALIFICATIONS: Registered Nurse with at least two (2) years experience in clinical documentation improvement, or case management and/or utilization review experience required, or RHIA or RHIT hospital inpatient coder with at least two (2) years current acute care coding experience and DRG analysis/management or documentation improvement experience required. Must have sharp analytical and critical thinking skills, must be highly detail oriented, have strong organizational, interpersonal and communication skills with ability to maintain confidentiality and positive relationships, energetic, goal and team oriented. Current Registered Nurse Licensure in the State of Texas, or Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT) required or Certified Clinical Documentation Specialist (CDIS) preferred.

Cook Children's Health Care System - 2 years ago - save job
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Cook Children's Health Care System is a not-for-profit, nationally recognized pediatric health care organization comprised of eight entities...