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Clinical Documentation Specialist

Company: Pro Health Medical
Location: Lynchburg
Posted on: July 15, 2019

Job Description:

The Clinical Documentation Specialist educates members of the patient care team on documentation guidelines on an ongoing basis. This position reviews patient medical records and prompts physicians and/or nurses for accurate and complete documentation in the patient's medical record. Applies knowledge of DRG payer issues, CDMP strategies and clinical, documentation requirements, to all duties as assigned. Clearly communicates and resolves documentation issues with physician and nursing staff. Collaborates with coding staff to assign appropriate DRG, based on clinical documentation in the medical record. Collaborates with the care delivery team and staff through attendance and participation in cross-functional team meetings Completes admission and follow-up reviews of documentation. Completes all job-specific training curriculum. Demonstrates an awareness of appropriate confidentiality rules and regulations and acts accordingly Educates all internal customers on clinical documentation opportunities and reimbursement issues. Identifies the most appropriate principal diagnosis and complications/comorbities to accurately reflect the severity of illness, in compliance with government regulations. Performs admission/continued stay reviews using CDMP and coding guidelines. Educational RequirementsBSNRN; BSN. 3 years recent acute care clinical experience in a hospital setting. Excellent written and verbal communication skills. Ability to organize, prioritize and work independently. Proficient computer skills5 years recent acute care clinical experience in a hospital setting.

Keywords: Pro Health Medical, Lynchburg , Clinical Documentation Specialist, Healthcare , Lynchburg, Virginia

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