GENERAL SUMMARY OF DUTIES
- The Clinical Documentation Specialist (CDS) conducts concurrent and retrospective review of the clinical documentation in the medical record to achieve more accurate and detailed documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient which will in turn improve the quality of patient care, more accurately portray the facility's quality outcomes ratings, reduce compliance risks, and capture appropriate reimbursement.Qualifications: EDUCATION
- 2 or 4 year undergraduate degree in Health Information Management, Nursing or health care related field strongly preferred.
- Equivalent work experience may substitute degree requirement.
- Completes Continuing Education requirements as determined by licensing/credentialing body.
- Minimum 3-5 years recent health information management, case management/utilization/quality review and/or other related clinical experience in an acute care facility required.
- Knowledge base of ICD-9-CM coding and understanding of Diagnostic Related Groups (DRGs) strongly preferred.
- RHIA, RHIT, CCS, RN or LPN required.
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