Title

Clinical Documentation Specialist- Health Information Services

About the Organization Beaufort Memorial, a not-for-profit hospital founded in 1944 on the banks of the Atlantic Intracoastal Waterway, is licensed for 201 beds (169 acute, 14 rehabilitation and 18 mental health). We are an acute-care hospital, a regional referral center and the largest medical facility between Savannah, Ga., and Charleston, S.C.



Fully accredited by The Joint Commission, Beaufort Memorial boasts a dedicated, high-quality medical staff of nearly 230 board-certified or board-eligible providers.



Our mission is to enhance the quality of life in the Lowcountry through improved health, innovative partnerships and superior care. Position Clinical Documentation Specialist- Health Information Services Location Beaufort Memorial Hospital Full-Time/Part-Time Full-Time Shift Days Exempt/Non-Exempt Exempt Description This position is responsible for performing concurrent review of the clinical documentation in the medical record. These duties include but are
not limited to:

• Using clinical judgment and clinical analytical skills, queries the medical staff and other care givers through written and verbal communication to obtain accurate and complete documentation that supports the severity of patient illness and risk of mortality, as well as allowing accurate assignment of ICD-9-CM codes that reflect the highest level of specificity that supports treatment provided.
• This includes querying for physician intent to assure identification and documentation of all co-morbidities and complications.
• Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.
• Uses clinical decision-making to identify “hints and clues” in the chart that would guide the physicians documentation toward clearly defined definitive diagnoses rather than non-specific signs and symptoms.
• Demonstrates creativity and enthusiasm while pursuing departmental and organizational goals.
• Maintains the ability to be flexible and prioritizes daily responsibilities.

Position Requirements

Education:

• A.D.N. or B.S.N.

Experience:

• Minimum of five years clinical experience in an acute care setting, preferably in medical/surgical with a current SC license as an RN.

Certifications/Licenses:

• Current South Carolina RN License.

EOE Statement Beaufort Memorial Hospital is an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.

This position is currently accepting applications.

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