Clinical Documentation Specialist
Tuomey Healthcare System
- Department: Clinical Documentation Integrity
- Customer relations skills required
- Experience is preferred
- Interpersonal skills required
- Organizational skills required
- Verbal skills required
Position Summary: Responsible for concurrent review and analysis of the clinical documentation in the medical records using query of the Medical Staff and other care givers as necessary with documentation query forms/verbal communication to obtain accurate and complete documentation that appropriately supports the severity of patient illness. Also assists in education of Medical Staff and other care givers relating to clarity and completeness of documentation. Abstracts quality information from the medical record. Completes reports and audit information. Maintains expertise in regulatory quality abstraction guidelines, definitions, rules and methods.
Qualifications: 2-year Associate's Degree. Prefer LPN or RN with coding experience or RHIA/RHIT. CCS, CPC, RHIT or RHIA certification preferred. 3-5 years of experience preferred. Computer skills required to include proficiency in using the Meditech System and Microsoft Office. Must be proficient in both ICD-9CM and CPT coding principles, medical terminology, anatomy, and physiology. Must have high level of confidentiality.
OSHA Category: Rare exposure to risk of bloodborne diseases (Category II). Rare exposure to risk regarding chemical hazards (Category B).
Physical Requirements: Exert up to 20 lbs. force occasionally, and/or up to 10 lbs. frequently. Prolonged standing, sitting, and walking. Performs repetitive tasks/motions. Must be able to distinguish colors.