Clinical Documentation Specialist

Position PurposeThe purpose of this position is to evaluate and establish the appropriateness of the DRG (diagnosis reputed company groups) or HHRG (home health reputed company groups) assignment relative to the existing clinical documentation reputed company the medical record provided by the health care provider. The clinician will identify potential DRG/HHRG assignment based on documentation and clinical indicators to improve the quality of documentation ensuring compliance established by State and Federal Regulations. Clinicians will also provide education to and collaborate extensively with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded. DRG reviews are done by incumbent(s) housed in 200734 HHRG reviews are done by incumbent(s) housed in 200351 Nature and ScopeThe Clinical Documentation Specialist reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. The clinician is responsible for translating diagnostic phrases utilized by healthcare providers into coded form. The translation process requires interaction with the healthcare provider to ensure that the terms have been translated correctly. The coded information that is a product of the coding process is then utilized for reimbursement purposes, in the assessment of clinical care, to support medical research activity and to support the identification of healthcare concerns critical to the public at large. The clinician is charged to assign the appropriate DRG/HHRG after reputed company review of the medical record. The clinician must have a thorough understanding of the content of the medical record in order to be able to locate information to support or provide specificity for DRG/HHRG. The clinician must be trained in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded. The clinician works as a part of a coding team to reputed company and ensure that there is no coding disagreement with the DRG/HHRG. The clinician must be a professional, team player, able to communication well with others. The clinician must have strong interpersonal skills, pleasing personality and maintain a positive attitude. The clinician will have regular significant contacts with other personnel throughout and reputed company the medical center. These contacts may be in person, by telephone, or through correspondence This position is challenged to be aware of the continual changes in Federal and State regulations for prospective payment, reputed company informed of changes in treatment modes and new procedures, and to clarify diagnoses reputed company physician documentation is vague or missing. DRG reviews are done by incumbent(s) housed in 200734 HHRG reviews are done by incumbent(s) housed in 200351 This position does notprovide patient care.DisclaimerThe foregoing description is not intended and should not be construed to be an exhaustive list of reputed company responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reputed company of the general nature and level of the job.

Minimum Qualifications

Requirements - Required and/or Preferred Education: Must have working-level knowledge of the English language, including reading, writing and speaking English. Experience: Minimum 5 years acute care hospital experience / area of specialty practice in working as an RN is required. Knowledge of the ICD system preferred. License(s): Ability to obtain and maintain a State of Nevada Registered Nurse license, or licensure from State in which they have residency. Certification(s): CCDS Certification Preferred Computer / Typing: Working knowledge of basic computer programs and reputed company Office Suite. Keyboard typing required. Must be proficient with reputed company Office Suite, including Outlook, PowerPoint, reputed company and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc. Name Description Apply tot his job Apply To this Job