Clinical Documentation Specialist

 •  Atos Origin Flint, MI

5 - 7 years experience  •  IT Consulting/Services

Salary depends on experience
Posted on 08/17/17
Flint, MI
5 - 7 years experience
IT Consulting/Services
Salary depends on experience
Posted on 08/17/17

Company Information

Atos is a leader in digital services with annual revenue of € 12 billion and 100,000 employees in 72 countries. Serving a global client base, Atos offers Consulting & Systems Integration, Managed Services & BPO, Cloud, Big Data & Cyber-security solutions.

With deep technology expertise and industry knowledge, Atos works with clients across many business sectors: Defense, Financial Services, Health, Manufacturing, Media, Utilities, Public Sector, Retail, Telecommunications, and Transportation.

Atos is focused on business technology that powers progress and helps organizations to create their firm of the future. In addition, Atos is the Worldwide Information Technology Partner for the Olympic & Paralympic Games and operates under the brands Atos, Bull, Canopy, Unify and Worldline.

Atos offers a broad professional perspective and the opportunity to build a rewarding career across either the technical or business paths.

With our worldwide presence and our broad range of professional services, Atos provides training programs across all our competencies and markets worldwide for employees in all stages of their career.

In addition, we offer programs that are focused on engaging and developing people who are at the beginning of their career through internships and graduate opportunities. 

Job Description

The Clinical Documentation Specialist facilitates the accurate representation of the severity of illness/risk of mortality by improving the quality, completeness and accuracy of the physicians clinical documentation through extensive medical record review and query process.

Through active engagement and interaction with physicians andother members of thehealthcare team, achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients.

Participates in the development and delivery ofeducation for providers andother members of thehealthcareteam.

Comprehends, incorporates, and demonstrates Anthelio Healthcare Solutions Mission, Vision, and Values in behaviors, practices, and decisions.

- Demonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the severity of illness,risk of mortality and level of services provided are accurately reflected in the health record.

Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes.

Serves as a resource for appropriate clinical documentation.

- Conducts concurrent medical record reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.

Ensures the accuracy and completeness of clinical information used for measuring andreporting physician and hospital pay for performance diagnosis specific quality outcomes.

- Communicates with and educates all members of thepatient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and pay for performance documentation requirements on an on-going basis.

- Collaborates with coding staff to ensure complete documentation of discharge diagnoses/co-morbidities are a complete reflection of the patients clinical status and care.

Resolves all discrepancies in a courteous manner.

- Develops and presents on-going documentationeducation for staff including case managers, coders, physicians, residents, nursing and allied health professionals.

- Gathers and interprets clinical documentation data; Identifies documentation concerns, discrepancies, or issues.

Determines methods to ensure compliance in accordance with clinical documentation policies and procedures.

- Utilizes interpersonal skills to discuss clinical documentation issues and work effectively with all levels ofinternal personnel such as coders, physicians, nursing and allied health professionals, and some external customers including third party payors to resolve issues.

- Understands and is able to articulate concepts to physicians andother health care professionals in an effort to educate clinical documentation requirements for both DRG reimbursement and pay for performance quality measures.

-Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinicalexperience and sound judgment. Serves as a role model by demonstrating professional practice behaviors.

- Performsother duties as assigned by Leadership.

- Maintains a working knowledge of applicable Federal, State and locallaws and regulations, accrediting agencies, AnthelioHealthcare Solutions Standards of Conduct, Code of Ethics, as well as,otherpolicies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

Job Requirements

-Must possess a comprehensive knowledge of acute care nursingexperience, as normally obtained through aBachelor of Science, Nursing (BSN) and at least fiveyears of current acute hospital careexperience (i.e. medical/surgical unit, intensive care).

-CurrentRegistered Nurse License in the State of practice.-Certified Clinical Documentation Specialist (CCDS)preferred.

-Certification will berequired within 1year and maintenance ofrequired ContinuingEducation Units (CEU).

-Experience inUtilization Management/Case Management, Critical Care, and patient outcomes/quality managementpreferred.-

Inpatient codingexperiencedesired.

-Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.

-Strong critical thinking skills and ability to integrate knowledge.

-Prioritization and organizational skillsrequired.

-Ability to educate all members of thehealthcare team related to clinical documentation.

-Demonstrated ability to use a standard desktop andwindows based computer system, including a basic understanding of email,internet, and computer navigation.

-Ability to useother software asrequired to perform the essential functions on the job.

-Experience with Microsoft Office Word, Excel and PowerPoint softwarepreferred.

-Comfortable operating independently in a collaborative,shared leadership environment.

- Possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivateothers to promote the philosophy, mission, vision, goals, and values of AnthelioHealthcare Solutions.

- Complete a clinical exam and achieve an80% passing score.

- Must be able totravel to variouslocations (20%) asrequired. 

Physical and Mental Requirements and working conditions:

Mental Requirements:

- Able to set and organize own work priorities, and adapt to change when needed.

-Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.

- Ability to comply with Anthelio Healthcare Solutions policies and procedures.

- Able to spend majority of time utilizing a computer, monitor and keyboard.

- Able to perform some lifting and/or pushing/pulling up to 20 pounds.

- Able to work with interruptions and perform detailed tasks.

- Proficient on working on different projects simultaneously and coordinate work to meet deadlines.

- Skilled ability to concentrate and read for long periods of time.

- Involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting, and reading.

- Must be able to sit for long periods of time.

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