Bothwell Regional Health Center

  • Clinical Documentation Specialist, 7a-3:30p, 80 Hours Per Pay Period

    Job Locations US-MO-Sedalia
    Posted Date 4 months ago(1/9/2018 3:25 PM)
    # of Openings
  • Overview

    The Clinical Documentation Specialist (CDS) is responsible for working with the Medical Staff and other healthcare professionals to improve the clinical documentation in the BRHC medical records. The CDS must be able to define problems, collect data, establish facts, and draw valid conclusions. The CDS must be able to interpret and deal with abstract and concrete variables and be able to effectively present information and respond to questions from physicians, other healthcare professionals, and hospital leadership.


    1. Continuously evaluates the quality of clinical documentation allowing for greater specificity of coding. Addresses incomplete or inconsistent documentation for inpatient encounters that may impact the code selection and resulting DRG groups and payment and /or E&M code assignments. Brings identified concerns to the medical staff or healthcare professional for resolution.


    1. Querying physicians currently on documentation issues impacting accuracy and specificity coding and DRG assignment.


    1. Maintains coding staff communications in public folders.


    1. Works and communicates in a cooperative, timely, respectful manner with leadership, supervisory staff, coworkers, and other health care personnel when providing information services, seeking assistance and /or clarification in resolving problems.


    1. Creates and monitors inpatient case mix reports and the top 25 assigned DRGs in the facility to identify patterns, trends, and variations in the facility’s frequently assigned DRG groups.       Once identified, the Clinical Documentation Specialist evaluates the causes of the change or problems and takes appropriate steps in collaboration with the right department to effect resolution or explanation of the variances.


    1. Facilitates open line of communication between coders, physicians, and case managers.


    1. In conjunction with HIM Director, communicates findings on quality reviews to Administration, Physicians, Coding Staff, and Compliance Committee.


    1. Assists in keeping the Discharged Not Final Billed less than 7 days revenue by identifying high dollar inpatient accounts for prioritization.


    • Education


          a.)  Graduate from an accredited school of nursing or accredited Health Information Management Program


    • Licensure/Certification


    a.) RN, RHIA, RHIT, or CCS


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