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.All activities will be performed in support of the strategy, vision, and values of Phoebe. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time. All activities must be in compliance with Equal Employment Opportunity laws, HIPAA, ERISA, and other regulations, as appropriate.
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.
Adheres to the hospital and departmental attendance and punctuality guidelines
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.
May be exposed to physical altercations and verbal abuse
Long-distance or air travel as needed - not to exceed 10% travel.
May be scheduled as needed including overtime
Have near normal hearing; Hear alarms/telephone/tape recorder/normal speaking voice
Have near normal vision: Clarity of vision (both near and far), ability to distinguish colors
Have good manual dexterity
Have good eye-hand-foot coordination
Ability to perform repetitive tasks/motion
Occasionally within shift (1-33%) : Climbing,Bending/Stooping,Lift/carry > 20 lbs with assistance,Reaching above shoulder,Lift/carry up to 20 lbs.
Frequently within shift (34-66%) : Walking,Sitting,Twist at waist,Pushing/Pulling.
Continuously within shift (67-100%) : Standing.
Certifications and Licensures
Required Certifications/Licensures : Registered Nurse (RN) with current Georgia license.
Preferred Certifications/Licensures : Clinical Documentation Specialist (CCDS).
Phoebe Putney Memorial Hospital