Clinical Documentation Specialist Nurse (On-Site) Full Time

Description: Are you interested in building a career with other TOP PERFORMERS?Effingham Health System is committed to providing exceptional care and services in an environment that supports professional growth, diversity, and inclusion. Every team member's experience and work-life balance are a priority in our organization.EHS culture encourages and supports individuals in pursuing their career goals and well-being by providing work-life balance, flexible scheduling, career development, and all the benefits and perks you need for yourself and your family.

Benefits:

• Retirement plans 403 (b) and 457
• Health insurance
• Dental Insurance
• Vision insurance
• Prescription Drug Plan
• Hospital Discount
• Flexible spending account
• Paid time off
• Extended Days off (Sick time)
• Employee assistance program
• Strive365 Wellness Program
• Basic Life insurance (Employer Paid)
• Voluntary Life insurance/Accident/Critical Illness
• Disability (LTD and STD)
• Tuition reimbursement
• Legal and ID Shield
• Discounted Gym membership
• Cafeteria Payroll Deduction
• Employee Perks Program
• Student Loan Relief and Assistance
• Employee Rewards and Recognition Program
• Bereavement Leave

Please Note: This is an ON-SITE position.

JOB SUMMARY

Under the general direction of the Revenue Integrity Manager, the incumbent is responsible to review medical records documentation for reimbursement, severity of illness and risk of mortality, identifies opportunities for improving the quality of medical record documentation and confers with the caregiver regarding additional documentation required. Ensures adherence to Joint Commission standards, federal, state, and all related local policies, procedures. Validates that the clinical documentation supports the charges. Provide a quarterly report of charge validation and charge validation concerns. Coordinates and administers training for clinical personnel that promotes standards and best practices. validation management.

Standards of Performance

• Analyzes for errors, updates, and distributes charge validation reports.
• Creates the physician and nurse deficiency list and sends it to the appropriate person.
• Assist the physician or nurse in completing the deficiencies
• Maintain the information flow according to established guidelines.
• Has the ability to perform all aspects of processing all records charge validation according to department policies and procedures.
• Ensures departmental adherence to proper infection control, OSHA and safety standards, Maintains work area in a neat, clean and organized manner.
• Responsible for maintaining organizational facilities in accordance with TJC, federal and state, organizational and departmental policies and procedures.
• Performs other duties as assigned, needed, required or requested.
• Applying knowledge of medical terminology and procedures to evaluate clinical documents.
• Collecting medical information from healthcare providers and updating medical records.
• Verifying the accuracy of patient medical information and obtaining missing information.
• Monitoring diagnoses, treatments, and follow-up entries in medical records.
• Interpreting and preparing clinical reports for healthcare professionals and public health officials.
• Meeting with healthcare stakeholders to explain findings and facilitate actions.
• Ensuring that the content and storage of medical documents comply with federal laws.
• Training medical and administrative staff in standard medical recordkeeping procedures.
• Keeping abreast of advancements in the field of clinical documentation and changes in regulations

Requirements:

Minimum Level of Education: Education level equivalent to completion of Associate degree in registered Nursing; BSN preferred.

Formal Training: In-depth knowledge of medical terminology, coding, and procedures. Skills with experience in critical thinking, analytics, planning, organizing, implementing, facilitating, interviewing, and counseling. Self-motivated and able to work independently without close supervision. Strong communication skills (interpersonal, verbal and written).

Licensure, Certification, Registration: Valid Georgia Nursing License, RHIA, RN, LPN, CDIP, CCDS

Work Experience: Minimum Three (3) years nursing, case management, utilization review or quality resources experience in an acute care setting required; Clinical Documentation Integrity experience highly desirable

Computer Skills: Proficient with Microsoft Office applications (Outlook, Word, Excel, PowerPoint).