Clinical Documentation Specialist Data Quality Viera FT Days
Health First, Incorporated - Viera, FL

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POSITION SUMMARY:
To

be fully engaged in providing uncompromised safety, superior quality, memorable patient/customer experiences, and financial stewardship by: collaborating with physicians, nursing, other licensed professionals to improve quality and completeness of documentation of care in the medical record. Clinical Documentation Specialists work with healthcare providers to ensure that clinical disease processes are properly documented reflecting the appropriate severity of illness and level of service rendered to our patients.

PRIMARY ACCOUNTABILITIES

Uncompromised Safety

1.

Identifies clinical and system breakdowns and recognizes improvement opportunities and refers them to appropriate areas (Case Management, Quality, Risk Management) for resolution.

2.

Always practices safe work habits and supports the National Patient Safety Goals.

3.

Participates in continuous quality improvement activities throughout the hospital.

Does Well > 90% of the time.

Improvement Required 90% of the time.

Improvement Required 90% of the time.

Needs Improvement 90% of the time.

Needs Improvement < 90% of the time

QUALIFICATIONS REQUIRED

1.

RN/LPN with five years acute care experience or RHIA/RHIT/CCS with 5 years inpatient coding experience.

2.

Clinical Documentation Certification preferred.

3.

Strong clinical background, critical thinking skills, knowledge of pathophysiology and disease processes, current treatment protocols, and correct documentation practices required.

4.

Current license to practice nursing in State of Florida.

5.

Bachelor’s degree in nursing or related science preferred.

6.

Demonstrates proficiency with computer applications including spreadsheet analysis, presentation programs, word processing and internet research.

7.

Proficiency in planning and organization.

8.

Strong interpersonal and excellent verbal and written communication skills.

9.

Ability to maintain positive working relationships within all levels of the organization.

10.

Analytical skills to recognize and resolve problems requiring technical or clinical interventions.

11.

Able to prioritize work and manage time.

12.

Ability and willingness to seek out and accept change.

PHYSICAL DEMANDS

1.

Able to stand, walk, sit, bend and travel large distances repeatedly, within the hospital in a timely manner.

2.

Ability to work flexible hours as needed.

3.

Must be able to lift 20 lbs. unassisted.

4.

Must be able to tolerate 3-5 hours of computer time per day.

5.

Must have visual acuity including near and far depth perception

6.

Must be able to hear and speak clearly.

MENTAL DEMANDS

1.

Ability to coordinate multiple tasks on an ongoing basis.

2.

Ability to adapt to changing organizational requirements and business applications.

3.

Ability to identify priorities and department needs.

4.

Be a self-starter.

5.

Committed to quality patient care.

6.

Ability to work in a TEAM environment effectively.

7.

Ability to effectively engage and communicate with a wide range of personalities.

COMPETENCY ASSESSMENT/SKILLS CHECKLIST

1.

Ability to communicate in tactful manner identified documentation needs found in the medical record.

2.

Must be able to prioritize multiple tasks.

3.

Must have working knowledge of coding and MS-DRG guidelines relative to Clinical Documentation.

4.

Must have working knowledge of insurance and payor issues relative to Clinical Documentation.

5.

Ability to work independently, in a high stress, public contact environment.

6.

Evidence of excellent assessment skills.

7.

Evidence of excellent oral and written communication and interpersonal skills.

8.

Ability to work with physicians and other hospital associates and departments.

9.

Demonstrates excellent relationship building skills with physicians.

10.

Demonstrates the ability to effectively engage a wide variety of personalities.

11.

Demonstrates computer competency and ability to fully utilize Health-first computer applications.

Qualifications

QUALIFICATIONS REQUIRED

1.

RN/LPN with five years acute care experience or RHIA/RHIT/CCS with 5 years inpatient coding experience.

2.

Clinical Documentation Certification preferred.

3.

Strong clinical background, critical thinking skills, knowledge of pathophysiology and disease processes, current treatment protocols, and correct documentation practices required.

4.

Current license to practice nursing in State of Florida.

5.

Bachelor’s degree in nursing or related science preferred.

6.

Demonstrates proficiency with computer applications including spreadsheet analysis, presentation programs, word processing and internet research.

7.

Proficiency in planning and organization.

8.

Strong interpersonal and excellent verbal and written communication skills.

9.

Ability to maintain positive working relationships within all levels of the organization.

10.

Analytical skills to recognize and resolve problems requiring technical or clinical interventions.

11.

Able to prioritize work and manage time.

12.

Ability and willingness to seek out and accept change.

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