What are the responsibilities and job description for the Clinical Documentation Specialist position at West Tennessee Healthcare?
Category : RN Professional
City : Jackson
State : Tennessee
Shift :
0 - Day (United States of America)
Job Description Summary :
Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. Facilitates appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality. Specific reviews are determined both internally and by requirements of external regulatory agencies. Plays a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services. Employee is under the direct supervision of the Manager of Clinical Documentation Improvement and the general supervision of the Department Director. A current RN license is required. Employee is subject to call back as required by the hospital.
ESSENTIAL JOB FUNCTIONS :
- Provides concurrent review of the clinical documentation in the medical record.
- Queries the medical staff and other caregivers as necessary to help establish accurate documentation, supporting appropriate severity of illness and risk of mortality.
- Performs thorough chart reviews to identify that co-morbidities, present on admission conditions, and complications are documented appropriately.
- Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.
- Assists in the development of APR / DRG / query response physician reports. Assists in analyzing reports to identify trends for physicians.
- Assists in providing information and in-services as necessary to physicians and ancillary staff.
- Performs related responsibilities as required or directed.
JOB SPECIFICATIONS : EDUCATION :
LICENSURE, REGISTRATION, CERTIFICATION :
EXPERIENCE :
KNOWLEDGE, SKILLS AND ABILITIES :
NONDISCRIMINATION NOTICE STATEMENT
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, ethnicity, disability, religion, national origin, gender, gender identity, gender expression, marital status, sexual orientation, age, protected veteran status, or any other characteristic protected by law.
