Tenet Healthcare Clinical Documentation Specialist 40hrs in Worcester, Massachusetts
Responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and documents findings. Facilitates modifications to clinical documentation to ensure completeness through extensive interaction with physicians or medical staff departments. Serves as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of documentation. Reports results of audits to departments and committees. Identifies opportunities for interdepartmental and interdepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities.
Excellent written and verbal communication skills, critical thinking skills and interpersonal skills to build effective partnering relationships with physicians, care management team, nursing staff, coding staff and hospital staff.
Graduate of an approved Health Information Technology/ Management program with credentials of RHIA, RHIA eligible, RHIT, RHIT eligible, CCS, CCS-P and /or graduate from an accredited nursing program with LPN or RN licensure. PHYSICAL REQUIREMENTS:
Ability to move throughout the department, hospital and other Saint Vincent Hospital locations. Visual skills, motor skills and the dexterity to operate a PC, fax, copy machine and telephones. Able to lift 25 pounds unassisted.
Two years of experience in acute care setting. Knowledge of care delivery documentation systems and related medical record documents. Computer skills and familiarity with basic office equipment required. Exposure to MS DRG coding classification preferred. SUPERVISORY RESPONSIBILITIES:
PROFESSIONAL LICENSURE AND CERTIFICATION REQUIRED:
RHIA, RHIA eligible, or RHIT, RHIT eligible, or CCS, CCS-P,or RN, LPN licensure REPORTING RELATIONSHIPS AND LEVEL OF AUTONOMY:
Directly reports to the Director of Health Information Management and collaborates closely the Coding Manager.
Organization: Saint Vincent Hospital
Title: Clinical Documentation Specialist 40hrs
Requisition ID: 1805009512