Clinical Documentation Specialist
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Job Description
Clinical Documentation Specialist improving inpatient records for Tidelands Health, South Carolina’s largest nonprofit healthcare provider. Reviewing clinical documentation, supporting coding accuracy, and educating medical staff on documentation requirements.
Responsibilities:
- Evaluate Medical Staff and healthcare team documentation daily under the Clinical Documentation Program
- Ensure quality and completeness of clinical documentation for Medicare, Medicaid and other payers for the inpatient population
- Analyze patients’ clinical status, treatment plans and medical histories to identify documentation gaps
- Collaborate with Coding staff to ensure discharge diagnoses and comorbidities accurately reflect patients’ clinical status and care
- Ensure timely, accurate and complete clinical information for measuring and reporting physician and hospital outcomes
- Conduct targeted second-level reviews of high- or low-outlier medical/surgical DRGs identified in quarterly PEPPER reports
- Assist with education for Medical Staff, Residents, designated Committees and hospital staff on obtaining appropriate medical-record documentation
- Contribute actively to departmental SMART goals supporting organizational strategic objectives
- Use monitoring tools to track Clinical Documentation Program progress
- Participate in implementing new service lines and identify documentation needs for new diagnoses and procedures
- Provide physician and staff education related to clinical documentation
Requirements:
- Bachelor's Degree required
- Bachelor's Degree in nursing or clinical degree in a related field preferred
- Two (2) years’ experience in the clinical field, coding, care management, or equivalent combination of education, training and/or experience demonstrating competence
- Strong clinical background
- Exceptional problem-solving, time-management and organizational skills
- Ability to work independently and communicate effectively and efficiently with Medical Staff and Healthcare Team
- Strong familiarity with medical practices, especially disease management and health and wellness programs
- Extensive knowledge of medical terminology and regulatory agency requirements
- Exceptional written and verbal communication skills
- Tact, initiative and confidence to perform the essential functions of the position
- One of the following required: Registered Nurse - South Carolina Department of Labor, Licensing and Regulation; Registered Health Information Administrator - American Health Information Management Association; or Certified Coding Specialist - American Health Information Management Association
- Light physical demand
Benefits:
- Day - 8 hour shift
- Year-round access to the Myrtle Beach area’s warm, sunny climate and outstanding quality of life
- Workplace culture built around inclusion, teamwork, mutual respect and recognition
- Equal Opportunity Employer
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