Clinical Documentation Specialist

York Hospital is looking for an experienced, Clinical Documentation Specialist. This is a full-time,#40 hours per week opening and is located in York, Maine. # The Clinical Documentation Specialist works as a team member within the operation of the #Clinical Coding Team#; supports medical staff by identification of clinical scenarios through interaction and collaboration with physicians, nursing and other members of the health care team to facilitate valid revenue recovery; reports to and performs other duties as assigned by the Leader Adult Health. # II## Principal Responsibilities and Duties # Maintains the York Hospital patient vision and adhere to the mission of the organization Analysis of targeted patient records (current and post discharge) to support appropriate reimbursement Demonstrates knowledge of DRG payer issues, documentation accuracies and clinical requirements Ensures the accuracy and completeness of clinical information used for measuring physician and hospital outcomes Educates internal customers on clinical documentation accuracies Maintain records that comply with current patient confidentiality regulations Report revenue recovered on a regularly scheduled basis Stay current with medical and regulatory changes by way of in-services, self-study and seminars Present or coordinate informative education to pertinent hospital and medical staff (one-on-one and in group meetings as needed) Cooperate and participate in a team setting to plan and follow through on agreed upon goals and strategies Will assign DRG including diagnosis and procedures to inpatient records Adheres to standards of ethical coding Is able to code and abstract outpatient records and have knowledge of CPT procedural coding as needed # # III# Working Relationships # Must be capable of working closely with medical and hospital staff Adheres to patient confidentiality policies of the hospital and federal and state laws Must be flexible in meeting job functions and work well under pressure Must have good writing and communication skills Must be able to work both independently and as a team member to accomplish the goals, objectives and strategies of the Coding team Participates in the CDMP user#s group if applicable # # IV## Qualifications # Nurse with current licensure in good standing who graduated from an accredited school of nursing or coder with 5+#years of experience providing both clinical documentation and coding services Minimum 3-5 years of progressive and relevant experience Excellent interpersonal skills for interfacing with physicians, and hospital staff in a way that builds mutual support, open communication, trust and confidence Management, teaching or business experience is helpful but not a requirement Computer literacy YORK HOSPITAL IS AN EQUAL OPPORTUNITY EMPLOYER.

York Hospital is looking for an experienced, Clinical Documentation Specialist.

This is a full-time, 40 hours per week opening and is located in York, Maine.

The Clinical Documentation Specialist works as a team member within the operation of the "Clinical Coding Team"; supports medical staff by identification of clinical scenarios through interaction and collaboration with physicians, nursing and other members of the health care team to facilitate valid revenue recovery; reports to and performs other duties as assigned by the Leader Adult Health.

II Principal Responsibilities and Duties

• Maintains the York Hospital patient vision and adhere to the mission of the organization

• Analysis of targeted patient records (current and post discharge) to support appropriate reimbursement

• Demonstrates knowledge of DRG payer issues, documentation accuracies and clinical requirements

• Ensures the accuracy and completeness of clinical information used for measuring physician and hospital outcomes

• Educates internal customers on clinical documentation accuracies

• Maintain records that comply with current patient confidentiality regulations

• Report revenue recovered on a regularly scheduled basis

• Stay current with medical and regulatory changes by way of in-services, self-study and seminars

• Present or coordinate informative education to pertinent hospital and medical staff (one-on-one and in group meetings as needed)

• Cooperate and participate in a team setting to plan and follow through on agreed upon goals and strategies

• Will assign DRG including diagnosis and procedures to inpatient records

• Adheres to standards of ethical coding

• Is able to code and abstract outpatient records and have knowledge of CPT procedural coding as needed

III Working Relationships

• Must be capable of working closely with medical and hospital staff

• Adheres to patient confidentiality policies of the hospital and federal and state laws

• Must be flexible in meeting job functions and work well under pressure

• Must have good writing and communication skills

• Must be able to work both independently and as a team member to accomplish the goals, objectives and strategies of the Coding team

• Participates in the CDMP user's group if applicable

IV Qualifications

• Nurse with current licensure in good standing who graduated from an accredited school of nursing or coder with 5+ years of experience providing both clinical documentation and coding services

• Minimum 3-5 years of progressive and relevant experience

• Excellent interpersonal skills for interfacing with physicians, and hospital staff in a way that builds mutual support, open communication, trust and confidence

• Management, teaching or business experience is helpful but not a requirement

• Computer literacy

YORK HOSPITAL IS AN EQUAL OPPORTUNITY EMPLOYER.