Clinical Documentation Specialist
The Hospital - Health Information Management (Medical Records)
Posted on 04/18/2013
The Clinical Documentation Specialist is responsible for reviewing medical records to ensure that all diagnoses, care, and treatment support patient care and accurate code assignment; improve coding specificity by educating physicians, clinicians, and others to provide complete and clear documentation of the care including medical necessity, capturing complications/co-morbidities; handle concurrent medical record review to track documentation supporting the severity of the illness/ medical necessity and the resources utilized facilitate the accurate representation of the severity of illness/medical necessity by improving the quality of the physician, nursing and therapy documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff and therapy staff. Active participation in team meetings and education of staff in the Clinical Documentation Improvement process is a key role.
RESPONSIBLE TO: DIRECTOR OF HEALTH INFORMATION MANAGEMENT
WORKERS SUPERVISED: NONE
Education: BA/BS in Health related field of study, BSN, or RN. RHIA, RHIT, CCS or CPC or other related certification preferred.
Training and Experience: The position requires a minimum of 3 years clinical experience in a hospital setting, preferably a Rehabilitation facility. Candidate must have strong knowledge of CMS, Medicare/Medicaid regulations, Private Insurance/Payor regulations, and Documentation standards/ regulations. The position requires the ability to communicate – verbally & written – with various customers. Must also have strong computer skills and the ability to work independently.
Send resume by 4/18/13 to:
The Children's Institute of Pittsburgh
1405 Shady Avenue
Pittsburgh, PA 15217
No phone calls, please. The Children's Institute of Pittsburgh is an Equal Opportunity Employer.
Send an email to inquire about this position.