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- Healthone
Description: - Clinical Documentation Specialist--RN,CCS or Inpatient Coding Specialist (03167-17873)Job DescriptionClinical Documentation Specialist--RN,CCS or Inpatient Coding Specialist(Job Number: 03167-17873)Colorado-Denver Metro-Swedish Medical CenterSchedule : Full-timeDescriptionPosition Summary:The Clinical Documentation Specialist facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients. The CDS will: Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans. Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospitals designated clinical documentation policies and procedures. Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness. Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record. Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team. Gather and analyze information pertinent to documentation findings and outcomes.QualificationsPosition Requirements:A. Licensure/Certification/Registration:Currently licensed as a Registered Nurse, CCS or Coding experience desirableB. Education:Prefer BS in Nursing or Registered Nurse with ten years acute care experience or RHIA/RHIT with ten years inpatient coding experience. Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient settingC. Experience:Five years acute care hospital experience.D. Knowledge/Skills/Abilities:Clinical expert with at least 2 years recent inpatient experience; Excellent verbal and written communication skills; Proficiency in organization and planning; Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching; Understanding of organizational policies and procedures; Working knowledge of quality improvement theory and practice; Ability and willingness to seek out and accept change; Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice; Knowledge of federal, state and private payer regulationsSend this job to a friend Send this job description to a friend by email. All the relevant details will be included in the message.Send this job to a friendJobCircle.com is the #1 local job board for jobseekers in the Mid-Atlantic Region. Visit JobCircle.com to search through 100,000 jobs and apply instantly online.