Clinical Documentation Specialist Full-Time Days

Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Will play a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting quality of care outcomes.

Education/Other Qualifications:

Minimum Education: Graduate of an accredited school of nursing, AHIMA accredited school, or international medical school.

Minimum Experience:

• Minimum of 3 years clinical or inpatient coding experience in an acute care setting required; 5 years experience strongly preferred.
• Famililarity with coding concepts and coding software desired.
• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff, and health information systems coding staff.
• Ability to work independently in a time-sensitive environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• Ability to stand and walk for periods of time is required in the performance of job responsibilities.
• Working knowledge of Medicare reimbursement system and coding structures/national coding guidelines

Required Certifications/Registrations/Licenses: Must possess a current RN or LPN license or an RHIA, RHIT, or CCS credential.

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Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.