Specialist, Clinical Document

Position Title: Specialist, Clinical Document Department: HIM Clinical Coding

Purpose:

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.

Report To:

Health Information Services Administrator

Supervisory Responsibility:

Direction: The job requires some accountability for scheduling, assigning or coordinating work.

Employees check the quality of work and provide guidance, instruction, training and direction to others. Although the job does not require formal or official supervisory responsibility, the incumbent serves as group leader or acts in an informal #assistant supervisory# or #lead# role. In addition, the employee may be expected to provide information or suggestions on human resources matters.

Materials Responsibility:

High: Work requires a high degree of responsibility for material resources.

Examples of resources could include large operating or capital budgets for a large functional area, major plants, facilities or properties, or other equivalent material assets. The employee has a large amount of control over these resources. The cost of errors might result in significant financial loss and affect overall corporate results. The difficulty, variety and depth of problems associated with these material resources is moderately complex.

Key Relationship:

Co-workers/Health System Employees, Outside Agencies/Other Health Care Providers, General Public/Visitors/Volunteers, Physicians/Medical Office Staff, Students/Interns/Residents/Outside Instructors, Patients, Families, and Significant Others, Third Party Payors/Insurance Companies, Auditors/Review Agencies # POSITION SPECIFICATION # Education: 4 year college/university degree or equivalent experience

Field Of Study:

Nursing

Special Training:

Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting

Training Preferred:

Knowledge of ICD and MS-DRG coding system; federal payment systems # Licensure/Registration: Registered Nurse in Iowa and/or Illinois

Experience:

More than 7 years experience required.

Interpersonal Skills:

Interaction is with a wide variety of people inside or outside the organization.

Communications are often extremely difficult or stressful in nature.

Contact with others involves highly complex and sensitive topics. The job requires extremely well developed interpersonal skills for dealing with a range of complicated problem situations. The job requires the use of diverse communication techniques.

Working Conditions:

There is exposure to some undesirable or unpleasant environmental characteristics.

The physical environment is generally safe and there is minimal health risk.

No safety equipment or unusual precautions are required. Exposure to these conditions would be limited to 70% or less of the work day.

Possible Exposure to Blood Borne Pathogens:

Yes

Miscellaneous:

Position Title: Specialist, Clinical Document

Department: HIM Clinical Coding

Purpose: 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.

Report To: Health Information Services Administrator

Supervisory Responsibility: Direction: The job requires some accountability for scheduling, assigning or coordinating work.

Employees check the quality of work and provide guidance, instruction, training and direction to others. Although the job does not require formal or official supervisory responsibility, the incumbent serves as group leader or acts in an informal "assistant supervisory" or "lead" role. In addition, the employee may be expected to provide information or suggestions on human resources matters.

Materials Responsibility: High: Work requires a high degree of responsibility for material resources.

Examples of resources could include large operating or capital budgets for a large functional area, major plants, facilities or properties, or other equivalent material assets. The employee has a large amount of control over these resources. The cost of errors might result in significant financial loss and affect overall corporate results. The difficulty, variety and depth of problems associated with these material resources is moderately complex.

Key Relationship: Co-workers/Health System Employees, Outside Agencies/Other Health Care Providers, General Public/Visitors/Volunteers, Physicians/Medical Office Staff, Students/Interns/Residents/Outside Instructors, Patients, Families, and Significant Others, Third Party Payors/Insurance Companies, Auditors/Review Agencies

POSITION SPECIFICATION

Education: 4 year college/university degree or equivalent experience

Field Of Study: Nursing

Special Training: Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting

Training Preferred: Knowledge of ICD and MS-DRG coding system; federal payment systems

Licensure/Registration: Registered Nurse in Iowa and/or Illinois

Experience: More than 7 years experience required.

Interpersonal Skills: Interaction is with a wide variety of people inside or outside the organization.

Communications are often extremely difficult or stressful in nature.

Contact with others involves highly complex and sensitive topics. The job requires extremely well developed interpersonal skills for dealing with a range of complicated problem situations. The job requires the use of diverse communication techniques.

Working Conditions: There is exposure to some undesirable or unpleasant environmental characteristics.

The physical environment is generally safe and there is minimal health risk.

No safety equipment or unusual precautions are required. Exposure to these conditions would be limited to 70% or less of the work day.

Possible Exposure to Blood Borne Pathogens: Yes

Miscellaneous: