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Clin Doc Integrity Spec I

Company: Prisma Health
Location: Columbia
Posted on: November 11, 2019

Job Description:

Job Details Associates Degree Required
BLS for Healthcare Providers required
2-4 years experience required
Job Summary:The Clinical Documentation Specialist is responsible for facilitating the accurate representation of the severity of illness and risk of mortality by improving the quality, completeness, and accuracy of the physicians' clinical documentation through extensive medical record review and query process. Through active engagement and interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients. This job also supports the clinical documentation used for measuring and reporting physician and hospital quality outcomes.?All team members are responsible for bringing life to our Purpose Statement ? Inspire health. Serve with compassion. Be the difference through every action and every interaction at work.?Responsibilities:Conducts concurrent medical record reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.Assists in overall quality, timeliness, and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes.Collaborates with care givers to ensure appropriate documentation to support the clinical picture and level of severity to inpatients for DRG-based payors.Queries physicians to obtain accurate documentation related to specificity of ICD-10 coding, severity of condition, co-morbidities, and length of stay.Maintains proficient knowledge of assessment, clinical disease process, and treatment.Supports timely accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes data.Demonstrates the ability to develop and maintain supportive, collaborative relationships with physicians to include education and follow up.Requirements:Education: Associate's degree in Nursing, Physical Therapy, Respiratory Therapy, or Health Information Management.Experience: Two years experience in adult medical/surgical/critical care/ER/PACU nursing, clinical documentation improvement, or inpatient coding.Number and Type of Team Members Supervised: NoneLicensure, Registry or Certification Required: Licensed as a Registered Nurse, RHIT, CCS, or CIC required. BSN, RHIA, CCDS, or CDIP preferred.?Current BLS (Basic Life Support for Healthcare Providers) required prior to start date directly through the American Red Cross, the American Heart Association, or the military. (To register: Blended Learning or In Person BLS through the American Red Cross; or Classroom or Skills Session BLS through the American Heart Association. Certification must include an in-person skills session.)Special Training: Must possess computer proficiency. Ability to handle stressful situations while remaining tactful.EEO/AA
Minorities/Females/Disabled/Veterans

Keywords: Prisma Health, Columbia , Clin Doc Integrity Spec I, Other , Columbia, South Carolina

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