JOB SUMMARY: Clincal Documentation Specialist - LOCATION: Reading Hospital
Provide clinically based, daily, concurrent and retrospective review of inpatient medical records.
Facilitation of appropriate provider documentation of patient care to accurately reflect severity of illness, intensity of service and risk of mortality.
Works collaboratively with the Providers and Coding staff to provide physician and staff education related to clinical documentation.
Knowledgeable of Federal, State and other payer regulations and requirements that will impact documentation.
Knowledge of the Medicare query guidelines.
Responsible to interact with the providers both verbally and in writing to obtain appropriate documentation clarification in the Medical Record.
Knowledge of the ICD 10 CM Coding guidelines and rules.
Obtain accurate and compliant documentation by providers for reimbursement for acute care services and in reporting quality outcomes.
Relevant Experience in Clinical Documentation
Strong clinical background in acute care with the ability to apply critical thinking skills resulting in effective communication with medical staff
demonstrated presentation skills for individuals and small groups.
Education and Certifications:
- CCDS or CDIP (required after 2 years in job)
- RN or LPN (if Nursing background)
- AHIMA Clinical Coding Specialist CCS (if coding background)
- DO, MD, NP, PA (if healthcare provider background)
- AAPC Certified Professional Coder- if outpatient coding background