3-5 years experience preferred
The Clinical Documentation Specialist performs concurrent and retrospective inpatient medical record reviews for Medicare and commercial payers to facilitate complete and comprehensive documentation reflective of clinical treatment, diagnosis, accurate severity of illness and risk of mortality; queries and follows up with physicians for clarification of ambiguous documentation or for co-morbid conditions and/or complications. The Clinical Documentation Specialist provides education to internal customers related to documentation compliance, coding and reimbursement; collaborates with multidisciplinary team of physicians, nurses, dieticians, HIM/Coding, Care Coordinators, and Utilization Coordinators; performs chart audits as needed; performs other duties as assigned. REQUIRED SKILLS: * Knowledge of interdisciplinary team concepts * Knowledge of software systems, such as CDR2, Midas, Cerner, Excel * Ability to give instruction in a manner that is easily understood by the learner * Able to gather and present data that is reliable regarding utilization measures such as LOS, CMI, etc * Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, impact of procedures on DRG and is able to impart this knowledge to physicians and other health team members. Graduate from accredited school of nursing
Current AZ RN license required
3-5 experience preferred
REQUIRED SKILLS: * Effective oral and written communication skills to communicate with customers and understand oral and written instructions. Must be positive, kind and caring. * Able to read, write and speak English in an understandable manner. * Requires a high level of analytic ability to identify and evaluate problems and recommend solutions. * Requires high level of accuracy, is capable of precise detail work in an organized manner. * Possess the ability to assess, document and implement actions required to meet customer needs and exceed their expectations. * Able to relate to and work with ill and disabled customers of all ages, bilingual customers, emotionally distressed customers and families, and with hospital personnel within the facility. * Able to cope with varying and unpredictable situations tactfully with personnel, patients, family members, visitors and the general public while maintaining a positive, empathetic attitude at all times. * Able to respond to emergency and crisis situations in a timely and professional manner. * Able to deal with high stress and high demand work environment.
- Able to work varying shifts/units, rotate days off, and work weekends.
Northern Arizona Healthcare - 18 months ago