Title: Clinical Documentation Spec Job

Date: May 10, 2024

Facility: Corporate (0100)

Summary

Responsible for daily interaction with physicians and practitioners to assign ICD-9-CM codes and obtain documentation. Evaluates documentation, communicates with physicians and other healthcare team members, acts as a resource in educating others and gathers/analyzes information pertinent to documentation findings and outcomes. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

Education/Experience/Licensure

	Education/Formal Training	Work Experience	Credential/Licensure
REQUIRED:	High School Deplomia/GED	Five (5) years of clinical experience or five (5) years in patient coding experience with advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting.	Currently licensed as a Registered Nurse Or Certified Coding Specialist (CCS) through AHIMA (American Health Information Management Association) Or RHIT/RHIA through AHIMA (American Health Information Management Association)
PREFERRED:	Bachelor’s degree in Nursing or successfully completion of the academic requirments of an HIM program cccredited by CAHIM or completion of an accredited coding training program.	N/A	N/A
SUBSTITUTIONS ALLOWED:	N/A	N/A	N/A

Knowledge/Skills/Abilities

In depth understanding of anatomy, physiology, medical terminology, and disease processes required.

Excellent verbal and written communication skills.
Proficiency in organization and planning.
Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching.
Working knowledge of quality improvement theory and practice.
Ability and willingness to seek out and accept change.
Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice.
Knowledge of federal, state and private payer regulations.

Key Job Responsibilities

Provides clinical evaluation of the medical record to facilitate capture of comprehensive medical record information to reflect clinical treatment, decisions, and diagnoses for inpatients.
Communicates with physicians and others to obtain appropriate information.
Provides or coordinates education to internal customers and acts as consultant to coders.
Gather and analyze information pertinent to documentation findings and outcomes.

Physical Requirements

The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
Must have good balance and coordination.
The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work.