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Clinical Documentation Specialist Job

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Date: Nov 23, 2021

Location: Memphis, TN, US

Company: Methodist Le Bonheur Healthcare

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.


Nearest Major Market: Memphis

Job Segment: Clinic, Physiology, Medical, Database, Medical Coding, Healthcare, Technology