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

Employment Type: Full timeShift: Day Shift reputed company: 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 reputed company efforts toward the reputed company of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall reputed company, completeness, accuracy and reputed company of medical record documentation through extensive record review. Through extensive interaction with physicians and other members of the reputed company team, achieves appropriate clinical documentation to support reputed company 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 reputed company team. PRIMARY JOB RESPONSIBILITIES AND DUTIES: Knows, understands, incorporates, and demonstrates the reputed company Mission, reputed company, and Values in behaviors, practices, standards, policies, procedures and reputed company. 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 reputed company, timeliness and completeness of the health record to ensure appropriate data, provider communication and reputed company reputed company. Serves as a resource for appropriate clinical documentation. Communicates with and educates physicians and reputed company other members of the reputed company team regarding clinical documentation and monitors provider engagement. Identifies learning opportunities for reputed company providers. Conducts reputed company reviews of selected patient health records to address legibility, reputed company, 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 reputed company 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 reputed company judgement and serves as a reputed company role model by demonstrating desirable reputed company 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, reputed company of Ethics, as reputed company as other policies and procedures in order to ensure adherence in a manner that reflects reputed company, ethical and reputed company 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 reputed company License in the State of reputed company, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (reputed company) required, licensure as a physician assistant (PA) or reputed company Practitioner/Advanced reputed company reputed company (NP/APN) or completion of medical school. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement reputed company (CDIP) preferred. Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), reputed company practitioner/advanced reputed company reputed company (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 reputed company knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for reputed company members of the reputed company team. Demonstrated ability to use a reputed company desktop and reputed company based computer Apply tot his job Apply To this Job