Clinical Documentation Specialist
OU Medical Center - Oklahoma City, OK

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General Description:
Under minimal supervision, responsible for ensuring the accuracy and completeness of clinical coding within the Health Information Management Department.

Essential Function/Duties:
Responsible for reviewing medical records for identifying payer population as directed on admission and throughout hospitalization. Analyzes status of patient, current treatment plan and past medical history to identify potential gaps in physician documentation. Based on the review, may query the physician verbally or in writing to assure the appropriate documentation in the medical record accurately reflects the patient’s illness. Prepares provider profiles. Prepares utilization analyses. Communicates with attending physicians to validate observations. Works closely with HIM coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.


Minimum Qualifications:
  • Education:
Bachelor's Degree in a healthcare related field



: Three (3) years experience in a healthcare related field with one (1) year of specific experience in clinical utilization, inpatient coding or charge audit.


Equivalent combination of education and experience

Knowledge, Skills and Abilities:
Must be knowledgeable about ICD-9-CM diagnosis and procedure codes and possess some clinical assessment skills. Ability to accurately code inpatient records. Requires knowledge of all payer issues concerning reimbursement and regulatory perimeters. Must be able to explain technical and complex information in such a way that health care providers can understand. Strong interpersonal skills that facilitate the gathering of information necessary for complete and accurate documentation are required. Strong computer skills are necessary. Must possess analytical skills necessary to clinically assess medical records documentation requirements.

Physical Requirements (with or without accommodation):
Must be able to balance, kneel, stoop and perform assigned duties under medium-stress. Work is light with some lifting and carrying. Work involves walking, standing, pushing and pulling of equipment. Work is primarily desk work and requires the ability to sit for up to 6 hours per day.

HCA Inc - 10 months ago - save job
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OU Medicine is the collaboration among OU Medical Center, The Children's Hospital, OU Medical Center Edmond, OU Physicians, OU...