We are seeking a Clinical Documentation Specialist to facilitate the accurate representation of the severity of illness/risk of mortality by improving the quality, completeness and accuracy of clinical documentation through extensive medical record review and query process.
Through active engagement and interaction with physicians and other members of the healthcare team, the Clinical Documentation Specialist achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients.
Demonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes.
Serves as a resource for appropriate clinical documentation.
Conducts concurrent medical record reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital pay for performance diagnosis specific quality outcomes.
Communicates with and educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and pay for performance documentation requirements on an on-going basis.
Develops and presents on-going documentation education for staff including case managers, coders, physicians, residents, nursing and allied health professionals.
Determines methods to ensure compliance in accordance with clinical documentation policies and procedures.
Bachelor's degree in a technical field such as computer science or English, journalism, communications 2-4 years of experience required
Experience in creating documentation for a technical audience
Source: Job Diva – Job Listing