Clinical Documentation Specialist

JOB SUMMARY

• Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive concurrent interaction with Physicians, nursing staff, other patient caregivers, and medical records coding staff to support that appropriate clinical severity is captured for the level of service rendered to all patients with a DRG based payor. Educates and functions as a resource to physicians, coding staff and others regarding best practice standards for clinical documentation and coding. Applies CMS, State and Hospital rules and regulations and practices in accordance with ethical standards of clinical documentation professional organization.

GENERAL REQUIREMENTS

• Adheres to the hospital and departmental attendance and punctuality guidelines

• Performs all job responsibilities in alignment with the core values, mission and vision of the organization

• Performs other duties as required and completes all job functions as per departmental policies and procedures

• Maintains current knowledge in present areas of responsibility (i.e., self education, attends ongoing educational programs)

• Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.

• Demonstrates competency at all levels in providing care to all patients based on age, sex, weight, and demonstrated needs. For non-clinical areas, has attended training and demonstrates usage of age- specific customer service skills.

WORKING CONDITIONS

• General environment: Works in a well-lighted, air-conditioned area, with moderate noise levels.

• May be exposed to limited hazardous substances or body fluids, or infectious organisms.

• May be required to change from one task to another of different nature without loss of efficiency or composure.

• Periods of high stress and fluctuating workloads may occur.

• Long-distance or air travel as needed - not to exceed 10% travel.

• May be scheduled as needed including overtime

EDUCATION REQUIREMENTS

• 2 year / Associate Degree in Nursing (Required)
• 4 year / Bachelor's Degree in Nursing (Preferred)

EXPERIENCE REQUIREMENTS

• 4 - 5 years advanced clinical expertise, extensive knowledge of complex disease processes with broad clinical experience in an acute hospital setting. (Required)
• 1 - 2 years Utilization review, quality or coding experience (Preferred)

CERTIFICATIONS AND LICENSURES

• Required Certifications/Licensures: Registered Nurse (RN) with current Georgia license

• Preferred Certifications/Licensures: Clinical Documentation Specialist (CCDS)

GENERAL SKILLS

• Organizational Skills

• Interpersonal Skills

• Customer Relations

• Mathematical

• Analytical

• Grammar / Spelling

• Read / Comprehend Written Instructions

• Follow Verbal Instructions

• Transcription

• Basic Computer Skills

• Microsoft Office Suite

• Strong critical thinking, judgement and decision making skills; ability to assess, evaluate and teach

• Strong communication skills (verbal and written) with ability to convey concise thoughts and content.

• Proficiency in use of computer and navigating electronic health record, databases and spreadsheets and performing internet searches.

• Able to prepare basic presentations, written reports and summaries.

PHYSICAL REQUIREMENTS

• Have good - manual dexterity and eye-hand-foot coordination

• Ability to perform - repetitive tasks/motion

PHYSICAL DEMANDS

• Standing

• Continuously within shift (67-100%)

• Walking

• Frequently within shift (34-66%)

• Sitting

• Frequently within shift (34-66%)

• Climbing

• Occasionally within shift (1-33%)

• Bending/Stooping

• Occasionally within shift (1-33%)

• Twist at waist

• Frequently within shift (34-66%)

• Pushing/Pulling

• Frequently within shift (34-66%)

• Lift/carry up to 20 lbs

• Occasionally within shift (1-33%)

• Lift/carry > 20 lbs with assistance

• Occasionally within shift (1-33%)

• Reaching above shoulder

• Occasionally within shift (1-33%)