Description
Summary:
The Clinical Documentation Specialist is responsible for facilitation improvement in the overall quality and completeness of the medical record documentation. Obtains appropriate documentation through extensive interaction with physicians, nursing staff, other patient caregivers and health information management coding staff to ensure that reimbursement if received for the level of services rendered to the patients and that the clinical information utilized in profiling and reporting outcomes is complete and accurate.
Requirements:
· RN; BSN preferred
· Basic computer skills in word processing and spreadsheet utilization.
· Excellent written and verbal communication skills.
· Demonstrates basic knowledge regarding HIM coding standards.
· Analytic skills necessary to accurately assess patient medical records.
· Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes.
· Ability to be flexible and adjust to workload/assignment changes and interruptions.
· Health Stream (HLC) modules completed by assigned date. Attend required meetings of operational communication.
· Minimum of 5 years recent experience in an acute care setting in a clinical nursing field preferred.
· Prior experience in clinical documentation improvement, quality management, case management or coding preferred.
· Licensed as a Registered Nurse in the State of Louisiana
· CPR required
Work Type:
Per Diem As Needed
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