CLINICAL DOCUMENTATION SPECIALIST HIM(Job Id 4565)
Job ID: 4565
Date posted: 04/30/2018
Work Type: FULL TIME
Department: HEALTH INFORM MGT STAFF
Shift/Hours: 8:00AM-4:30PM Monday-Friday
: FULL TIME Facility: GWINNETT MEDICAL CENTER Other information:
Department: HEALTH INFORM MGT STAFF Shift/Hours
: 8:00AM-4:30PM Monday-Friday
This position is part of a team whose primary responsibility is to improve the overall quality and completeness of clinical documentation in the medical record. This position will facilitate improvement in documentation through interaction with physicians and other members of the healthcare team and medical record coders to support the assignment of the most accurate DRG that best reflects acuity of illness. This position ensures the accuracy and completeness of clinical information used for measuring and reporting physician and Gwinnett Hospital System outcomes. This position will collaborate with other clinical teams and physician coaches to ensure documentation supports length of stay, resource utilization and patient outcomes. This position will serve as an educational resource to all members of the healthcare team on an ongoing basis on issues related to clinical documentation.
- This position requires a current licensure in Georgia for Registered Nurse or Registered Respiratory Therapist (RRT) or
RHIA/RHIT or CCS with 5 plus years Inpatient coding experience.
- Two plus years CDI experience and CCDS or CDIP preferred.
- Experience in an acute inpatient care setting through the areas of direct patient care, utilization review, case management or quality review. Critical care experience preferred.
- Experience in documenting in medical records in an acute care setting and the ability to develop successful interactions with physicians and other healthcare staff.
- Highly developed communication skills and strong clinical decision-making ability required.
- High degree of motivation with demonstrated leadership skills and strong organizational skills required in order to encourage a spirit of mutual cooperation and to participate in a process from beginning to completion.
- Requires demonstrated characteristics necessary to function as part of a cohesive, productive team. Requires the ability and desire to learn and develop skills necessary to perform.
- Knowledge of DRG payor issues including documentation requirements and reimbursement policies strongly desired.
- Ability to perform computerized data entry and work with CDI/coding software.
- Ability to perform detailed presentations for large and small groups.