Clinical Documentation Specialist

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