Responsibilities:Reviewing clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician's clinical documentation. This work involves extensive record review and interaction with physicians, HIM/Coding professionals, nursing staff, and case management. Through collaboration with Coding professionals, educates the patient care team on changes in documentation guidelines and/or documentation deficiencies noted. The patient care team includes but is not limited to: attending physicians, consultants, physician extenders, allied health practitioners, nursing, and case management. The Specialist reports to the Clinical Documentation Improvement Director.
Qualifications:Education- Associates Degree in nursing, Health Information Management or a related field Required
- Bachelors Degree Bachelors degree Preferred
Work Experience- 5 years of recent hospital experience/practice, preferably in an ICU, CCU or complex Med/Surg environment Required
- Previous clinical documentation improvement experience, utilization management, precertification, coding, Medicare regulations, quality assurance, or related area Preferred
- Prior experience with Epic Preferred
Licenses and Certifications- Must have one of the following: Upon Hire Required
- RN - Registered Nurse - Georgia State Licensure and/or NLC/eNCL Multistate Licensure Required or
- CCS-Certified Coding Specialist Required or
- RHIT - Registered Health Information Technician Required or
- RHIA - Registered Health Information Administrator Required or
- CCDS - Certified Cardiac Device Specialist Required
Business Unit : Company Name: Piedmont Healthcare Corporate
