Clinical Documentation Specialist--RN,CCS or Inpatient Coding Specialist Job

Primary Location: Colorado-Denver Metro-Swedish Medical Center Job: Case Management Schedule: Full-time

Description:
Position Summary: The Clinical Documentation Specialist facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients. The CDS will: Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans. Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures. Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness. Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record. Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team. Gather and analyze information pertinent to documentation findings and outcomes. Position Summary: The Clinical Documentation Specialist facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients. The CDS will: Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans. Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures. Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness. Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record. Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team. Gather and analyze information pertinent to documentation findings and outcomes.

Nearest Major Market: Denver
Job Segments: Clinic, Healthcare, Medical Assistant, Medical Coding