At Saint Francis Hospital Bartlett - the Clinical Documentation Specialist provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk mortality. Will play a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting quality of care outcomes. Will also collect data regarding timeliness of report completion to assist physicians in meeting the Saint Francis Hospital – Bartlett Rules and Regulations for timely and complete record documentation as well as JCAHO standards and CMS guidelines. Verifies the documentation of the correct admission type and follows up on incorrect assignments immediately.
Must possess a current RHIA, RHIT or CCS credential, valid RN or LPN TN license or bachelors degree in health related field. Graduates of foreign medical schools would also be considered.
Minimum of 2 years clinical or inpatient coding experience or the equivalent in an acute care setting is required. 5 years strongly preferred.
Familiarity with coding concepts and coding software desired.
Knowledge of care delivery documentation systems and related medical record documents.
Knowledge of age-specific needs and the elements of disease processes and related procedures.
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
Excellent written and verbal communication skills.
Excellent critical thinking skills.
Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff and health information systems coding staff.
Ability to work independently in a time-sensitive environment.
Ability to perform basic statistical calculations.
Proficiency in Windows-based applications
Ability to assign a preliminary DRG on admission
Certifications: RHIA (Registered Health Information) or RHIT (Registered Health Information Technician) Management) or CCS (Certified Coding Specialist) or RN/LPN license required.
Saint Francis Hospital - Bartlett