Clinical Documentation Specialist
Snellville , Georgia
September 07, 2017
Eastside is a 310-bed, full-service, acute care medical center with nearly 1,200 employees and 450 affiliated physicians. The hospital is fully accredited by The Joint Commission. Eastside Medical Center has been a leader for 31 years in a wide range of state of the art healthcare, including emergency services, neurosurgery, orthopaedics, women's services, neurosciences, oncology, cardiology and behavioral health.

Position Responsibilities:

  • Analyzes inpatient records for status of the patient, current treatment plan and past medical history to identify potential gaps in physician documentation.
  • Based on the review the Clinical Documentation specialists may query the physician verbally and/ or in writing to assure the appropriate documentation is documented in the body of the medical record, to capture the patient's severity of illness.
  • Able to communicate with attending physicians and residents to validate observations
  • Able to work closely with the HIM coding staff to assure documentation of discharge diagnosis and any co-existing, co-morbidities that are a complete reflection of the patient's clinical status and care.

Qualifications :

  • Minimum of 2 years hospital experience required.
  • Recent coding experience ,
  • Utilization Review or Case Management Experience preferred
  • Bachelor's degree in healthcare related field preferred
  • RN or RHIA preferred

Special Skills Required:
  • Must possess advanced communication and interpersonal skills with all levels of internal and external customers.
  • Must demonstrate excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills.
  • Must be proficient in organization and planning.
  • Must possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching.
  • Must demonstrate working knowledge of quality improvement theory and practice.
  • Must have working knowledge of DRGs and medical necessity criteria.
  • Knowledgeable of Federal, State, and other payers' regulations, requirements, and criteria.

Degree of Supervision Required : Minimal, must be able to work independently

Employees Supervised : NA

A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom

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