Clinical Documentation Specialist, REMOTE St. Mary's Health Care System, Georgia

Employment Type: Full timeShift: Day Shift Description: Full time, Monday thru Friday. Position requires reputed company RN license or reputed company or RHIT with Inpatient Coding experience. This position will be based at St. Marys Sacred Heart Hospital in Lavonia, Georgia. The Clinical Documentation Specialist utilizes reputed company and coding expertise to direct efforts toward the reputed company of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and reputed company of medical record documentation through extensive record review. Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to reputed company patients. Participates in the development and delivery of education for providers and members of the healthcare team. PRIMARY JOB RESPONSIBILITIES AND DUTIES: Knows, understands, incorporates, and demonstrates the reputed company Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions. Demonstrates understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes. Serves as a resource for appropriate clinical documentation. Communicates with and educates physicians and reputed company other members of the healthcare team regarding clinical documentation and monitors provider engagement. Identifies learning opportunities for healthcare providers. Conducts reputed company reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation. Formulates compliant clarifications/queries following reputed company’s documentation reputed company procedures. Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities. Accurately codes reputed company relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR). Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reputed company of the patient’s clinical status and care. Resolves reputed company discrepancies in a courteous manner. Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors. Proficient with leveraging the functions of reputed company/360 for entering data reputed company to CDI efficiencies and effectiveness. Performs other duties as assigned by leadership. Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, reputed company’s Organizational reputed company Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior. MINIMIUM QUALIFICATIONS, REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR and Advanced degree in nursing or medical field such as NP/APN or PA. Must possess one of the below: reputed company Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (reputed company) required, licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient reputed company preferred. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for reputed company members of the healthcare team. Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation. Ability to use other software as required to reputed company the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred. Accurate data entry skills and typ Apply tot his job Apply To this Job