The Clinical Documentation Specialist is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians' clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. The CDS will participate in team meetings and education of staff is a key role.
Accurate and timely record review
Recognize opportunities for documentation improvement
Ability to access, manage and update patient medical records through Hospital Electronic Medical Record Information System
Formulate clinically credible queries
Effective and appropriate communication with physicians
Timely follow up on all cases especially those with queries
Participate in Task Force meetings
Manage multiple priorities
Knowledge of Medicare Part A
Familiar with Medicare Part B
Communicates with HIM staff and resolves discrepancies
The information above is for summary purposes, and is not intended to be a comprehensive list of essential functions.
Bachelor degree related to the applicable clinical area of responsibility, such as nursing, nursing administration, rehabilitation, or other clinical field, required
Valid license or certification in the applicable clinical area of responsibility, in the State of practice, required
Five years of experience in progressive clinical positions, required
Excellent communication and interpersonal skills, required
We reveal and foster God's healing love by improving the health of the people and communities we serve, especially those who are poor and vulnerable.
Inspired by our faith,
•We will be distinguished as the premier person-centered health system and trusted partner.
•We will share accountability with clinicians and other stakeholders to coordinate care across all settin...gs and improve access, quality, health outcomes, and affordability.
•We will grow as community-based health networks to serve more people in partnerships with others who share our vision and values.
Caring Spirit - We honor the sacred dignity of each person.
Excellence - We set and surpass high standards.
Good Humor - We create joyful and welcoming environments.
Integrity - We do the right thing with openness and pride.
Safety - We deliver care that seeks to eliminate all harm for patients and associates.
Stewardship - We are accountable for the resources entrusted to us.