CLINICAL DOCUMENTATION SPECIALIST (RN or RHIT/RHIA)
Ref: : 30027
Location: Berwyn - Illinois
Rate: N/A (Permanent) + Healthcare Insurance Benefits
Reporting to the Manager of Coding is responsible for improving the overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and document findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient care givers and medical records coding staff. Serves as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality and final code assignment. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Monitors and evaluates the effectiveness of concurrent chart review and query outcomes at designated intervals. Maintains accurate records of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and interdepartmental operational improvements. Performs monthly closed chart reviews and serves on the Chart Documentation Committee. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities.
