What are the responsibilities and job description for the Clinic Documentation Specialist -Medical Records position at St. Luke's Duluth, MN?
Summary
- JOB SUMMARY
- The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with providers, other patient caregivers and Health Information Management Department coding staff to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis.
- MINIMUM QUALIFICATIONS
- Education: Graduate of an accredited School of Nursing.
- Experience: Two (2) years recent clinical experience in acute care hospital ICU, emergency department, or med/surg department; -OR- One (1) year clinical documentation improvement experience with knowledge and/or experience related to ICD code assignment and DRG assignment.
- Licensure/Certification/Registration: Current RN license.
- PREFERRED QUALIFICATIONS
- Education: Bachelors Degree in Nursing.
- Experience: Knowledge of Medicare Parts A and B; ICD coding experience; experience working directly with physicians.
- Licensure/Certification/Registration: Certified Coding Specialist (CCS) certification.
- KNOWLEDGE, SKILLS AND ABILITIES
- Ability to effectively communicate with medical staff, health care personnel and third party payors. Ability to effectively communicate and work closely with other case managers and all members of the health care team in such fashion as to make the program a continuing functioning process. Ability to function with dependability, diplomacy and initiative. Understands that St. Lukes is committed to following ethical procedures and remaining within the boundaries of the St. Lukes Compliance Plan.
- READING - Intermediate: Ability to read and interpret documents such as operating and maintenance instructions and procedure manuals.
- WRITING - Intermediate: Ability to write routine reports, correspondence, or procedures.
- SPEAKING - Intermediate: Ability to effectively present information in one-on-one, small group situations or before groups of customers, clients, and other employees of the organization.
- MATHEMATICAL SKILLS - Intermediate Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals and to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to compute rate, ratio, and percent and to draw or interpret bar graphs to apply concepts of basic algebra and geometry.
- REASONING ABILITY - Intermediate Skills: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
- AGE SPECIFIC COMPETENCIES - Skilled at assessment and knowledgeable of growth and development. Provides appropriate care respective to the ages of the patients served per clinical environment.
- PHYSICAL DEMANDS AND ENVIRONMENT
- PHYSICAL DEMANDS
- Ability to see, hear, walk, talk, sit, stand, reach and work greater than eight (8) hours per day; ability to lift up to twenty-five (25) pounds
- Stand - Occasionally Under 1/3 (1-2.5 hours)
- Walk - Occasionally Under 1/3 (1-2.5 hours)
- Sit - Continuously Over 2/3 (5.5 – 8 hours)
- Use hands to finger, handle, or feel - Continuously Over 2/3 (5.5 – 8 hours)
- Reach with hands and arms - Occasionally Under 1/3 (1-2.5 hours)
- Stoop, Squat, Kneel, or Crouch - Occasionally Under 1/3 (1-2.5 hours)
- Bending-repetitive forward - Occasionally Under 1/3 (1-2.5 hours)
- Talk or hear - Continuously Over 2/3 (5.5 – 8 hours)
- LIFTING REQUIREMENTS
- Up to 10 pounds - Frequently 1/3 to 2/3 (2.5 – 5.5 hours)
- Up to 25 pounds - Occasionally Under 1/3 (1-2.5 hours)
- WORK ENVIRONMENT
- Typical Noise Level - Moderate noise (examples: business office with computers and printers, light traffic)
- WORKING CONDITIONS
- Works in an office-based clinical setting. May be exposed to unpleasant patient elements.
