Clinical Document Specialist
Lovelace Medical Center - Albuquerque, NM

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Works in tandem with medical staff, nursing staff, other healthcare professionals, and coding staff to ensure accurate capture of clinical information through chart review, querying, and education. Specialists review charts for accurate documentation for reimbursement purposes and for designated core measures and quality indicators. Ensures the overall quality and completeness of medical record clinical documentation. Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregivers, and coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis.

Education: Bachelor’s degree in a health related profession, or Associate’s degree with relevant healthcare experience (equivalent to bachelor’s), or registered licensed nurse (RN)

Knowledge of McKesson Star and HPF, 3M Coding and Reimbursement System, SMART
Working knowledge of ICD-9-CM and Prospective Payment System (preferred)

Essential Technical/Motor Skills: Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication.

Interpersonal Skills: Professional, team player, able to communicate well with others on all levels. Strong interpersonal skills, pleasing personality, positive. Regular significant contacts with other personnel throughout and outside the Hospital. Contacts may be in person, by telephone, or through correspondence.

Leadership Qualities: Ability to motivate, teach and acilitate individuals and/or groups on reaching objectives.

Minimum 5 years recent clinical experience in nursing or other clinical area, coding, process improvement, or utilization review/case management in an acute care facility.

RHIA, RHIT, RN (preferred)

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