Clinical Documentation Specialist

Job Description

Job Description

Description:

Opportunity for Full Time Days Monday-Friday

Will be on site

Clinical Documentation Specialist will ensure the overall quality and completeness of clinical documentation in patient medical records through extensive concurrent review, and concurrent interaction with physicians, care team members, case management, health information management and others as applicable. Monitors the documentation process and facilitates modifications to documentation to ensure clinical severity and intensity of service is documented to support the level of service and treatment rendered, to ensure accurate description of reasons for admission, patient severity, risk of mortality and conditions present on admission.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Review inpatient medical records using EMR for identified payer populations on admission.

2. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation. 

3. Works collaboratively with the coding staff to ensure documentation of principal diagnosis.

4. Facilitates modifications and improvements to clinical documentation.

5. Track successes and opportunities of the program by analyzing data obtained from tracking reports.

6. Collaborates with Case Management, Quality Improvement and other individuals.

7. Participates in committees as assigned and with planning and delivering educational initiatives. 

8. Coordinates and facilitates team meetings in collaboration with the coding staff and others, as required.

9. Other duties as assigned.

Community First Medical Center offers benefits to all its full-time and part-time employees: 

• United Healthcare Medical PPO/HMO/HSA Plans, premiums as low as $50.00/full time, $85.00/Part Time
• Met Life Dental and Vision
• Paid Time Off (PTO) with annual accruals up to 168 hrs./year
• Six paid holidays
• Company Paid Life insurance and Short-term Disability 
• 401(k) after 90 days
• Continuing Education reimbursement and 2 days paid off separate from PTO
• Free Parking Garage
• Internal Growth Opportunities

Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience  

• Must effective writing skills, critical-thinking and problem- solving skills, be self-motivated and manage deadlines.
• Must have strong interpersonal skills to effectively interact with a variety of staff.
• Graduate of an accredited school of nursing with current Illinois license, required. 
• Bachelor’s Degree in Nursing, Medicine or Associate’s degree in Health Information 
• Management with RHIT credentials required, Bachelor’s Degree in Health Information Management preferred. 
• R.N. must have a minimum of 5 years of recent acute care experience.
• HIM professionals must have a minimum of 3 years of recent in-patient, acute care coding experience.
• RN, RHIT or RHIA with 2 yrs. experience in a clinical documentation specialist role or Utilization Review.
• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT), preferred
• Knowledge of MS-DRG and reimbursement principles
• Knowledge of Microsoft Word, Outlook, electronic medical record
• Knowledge of EPIC patient information systems preferred. 
• Knowledge of a 3rd party clinical documentation management application preferred

Community First Medical Center is an affirmative action/equal opportunity employer who is committed to cultivating diversity, equity and inclusion within all aspects of our organizations. We stand against and prohibit discrimination in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.