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 of mortality. Will play a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting quality of care outcomes.
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 essential functions.
Education/Other Qualifications 1. Graduate of an accredited school of nursing, AHIMA accredited school, international medical school 2. Must possess a current RN or LPN license or an RHIA, RHIT, CCS, CIC, MD, DO, PA or NP credential. 3. 0-2 years of CDS experience and 2 years recent acute care experience in a clinical or inpatient coding setting; or MBBS and USMLE in lieu of experience. 4. Familiarity with coding concepts and coding software desired. 5. Knowledge of care delivery documentation systems and related medical record documents. 6. Knowledge of age-specific needs and the elements of disease processes and related procedures. 7. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. 8. Excellent written and verbal communication skills. 9. Excellent critical thinking skills. 10. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff, and health information systems coding staff. 11. Ability to work independently in a time-sensitive environment. 12. Computer literacy and familiarity with the operation of basic office equipment. 13. Assertive personality traits to facilitate ongoing physician communication. 14. Ability to stand and walk for periods of time is required in the performance of job responsibilities. 15. Working knowledge of Medicare reimbursement system and coding structures/national coding guidelines.
Job: Medical Records
Primary Location: Mount Pleasant, South Carolina
Facility: East Cooper Medical Center
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 2105007580
About East Cooper Medical Center
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.