Clinical Documentation Specialist
Department: HIM - Coding
Schedule: Full Time
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and Health Information Management Department coding staff to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis.
BSN or AD with active enrollment in BSN degree program with 5 years experience in nursing. ICU or E.D. experience is preferred also. Must possess and consistently demonstrate strong interpersonal communication skills. Ability to interact well with physicians and other members of health care team, including HIM coders. Must be computer literate.
BLS is required for any RN, LPN, PCT, Patient Transporter or other direct patient care provider. Emergency Department, Intensive Care Units, PACU, Medical Emergency Team and Anesthesia require ACLS. Pediatrics, SICU, Emergency Department and Medical Emergency Team also require PALS
Location/Region: Rogersville, TN (US)