Clinical Documentation Specialist - Piedmont Medical Center
Job ID 2005030808
Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate thedocumentation and utilization of acute care services.Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality.Will play a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting quality of care outcomes.
Minimum Education: Graduate of an accredited school of nursing, AHIMA accredited school, or international medical school.
Minimum of 3 years clinical or inpatient coding experience in an acute care setting required; 5 years experience strongly preferred.
Famililarity with coding concepts and coding software desired.
Knowledge of care delivery documentation systems and related medical record documents.
Knowledge of age-specific needs and the elements of disease processes and related procedures.
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
Excellent written and verbal communication skills.
Excellent critical thinking skills.
Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospitalmanagement staff, and health information systems coding staff.
Ability to work independently in a time-sensitive environment.
Computer literacy and familiarity with the operation of basic office equipment.
Assertive personality traits to facilitate ongoing physician communication.
Ability to stand and walk for periods of time is required in the performance of job responsibilities.
Working knowledge of Medicare reimbursement system and coding structures/national coding guidelines. Required Certifications/Registrations/Licenses:Must possess a current RN or LPN license or an RHIA, RHIT, or CCS credential.
PRIMARY LOCATION:Rock Hill, South Carolina
FACILITY:Piedmont Medical Center
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy),