Clinical Documentation Specialist, Case Management, Full Time, Flexible Shift

Position Summary:

Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Include 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.

Position Qualification: (Training, Education, Experience, Skills and Abilities) Preferred:

• 5 years Clinical or Inpatient coding experience preferred.

EDUCATION: RN or LPN license or RHIA, RHIT, or CCS credential; a graduate of a foreign medical school would also be considered.

TRAINING: Orientation and training under supervision of HIM Director and Coding Manager until competency is observed.

ABILITIES AND SKILLS:

• Familiarity with coding concepts and coding software desired. Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff, and health information management coding staff.
• Ability to work independently in a time-sensitive environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• Ability to stand and walk for periods of time is required in the performance of job responsibilities.
• Working knowledge of Medicare reimbursement system and coding structures/national coding guidelines.

EXPERIENCE: 3 years clinical or inpatient coding experience in an acute care setting required; 5 years’ experience strongly preferred.

Required Licenses/Certifications: RN, LPN, RHIA, RHIT, CCS, or Foreign Medical Graduate.

Language Skills:

• Ability to effectively communicate (verbally and in writing) in English.
• Ability to write legibly (Clinical Areas).
• Additional languages desirable.