Prime Healthcare

Clinical Documentation Specialist

Facility Southern Regional Medical Center
Location
US-GA-Riverdale
ID
2022-103409
Category
Business Professional
Position Type
Full Time
Shift
Days
Job Type
Non-Exempt

Overview

Join an award-winning team of dedicated professional committed to our core values of quality, compassion and community! Southern Regional Medical Center, a member of the Prime Healthcare Foudnation, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.

 

Southern Regional Medical Center is a non-profit, 331-bed community hospital serving the residents of Clayton County and Southern Atlanta communities. The hospital offers a complete line of services including Senior Care and Senior Behavioral Health Services; Emergency Services; Heart and Vascular; Advanced Imaging; Laboratory; Neuroscience Services; Rehabilitation; Sleep Diagnostic Center; Surgery/Robotic Surgery; Wound Care; and Women's Health Services, including a Level III NICU. The hospital is accredited as a Chest Pain Center and Primary Stroke Center. Learn more at southernregional.org

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible conducting clinically based concurrent and retrospective reviews of inpatient medical records. This review is to evaluate that the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided. The CDS will work closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings.

Qualifications

Education and Work Experience

  1. Medical Graduate, PA or Nursing Graduate required.
  2. ECFMG Certificate or RN license preferred.
  3. Please note that in order to be promoted to CDS I position, the Employee must meet certain performance standards as defined by the Hospital/ Department.
  4. Minimum of 1+ year's clinical experience in an acute care setting.
  5. Knowledge of care delivery documentation systems and related medical record documents.
  6. Knowledge of age-specific needs and the elements of disease processes and related procedures.
  7. Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
  8. Excellent written and verbal communication skills. Excellent critical thinking skills.
  9. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
  10. Working knowledge of inpatient admission criteria.
  11. Ability to work independently in a time-oriented environment.
  12. Computer literacy and familiarity with the operation of basic office equipment.
  13. Minimum of 1+ year's clinical experience in an acute care setting.
  14. Knowledge of care delivery documentation systems and related medical record documents.
  15. Knowledge of age-specific needs and the elements of disease processes and related procedures.
  16. Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
  17. Excellent written and verbal communication skills. Excellent critical thinking skills.
  18. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
  19. Working knowledge of inpatient admission criteria.
  20. Ability to work independently in a time-oriented environment.
  21. Computer literacy and familiarity with the operation of basic office equipment.
  22. Assertive personality traits to facilitate ongoing physician communication.
  23. Working knowledge of Medicare reimbursement system and coding structures preferred.
  24. Current BCLS (AHA) certificate upon hire and maintain current; preferred.
  25. ACLS preferred.

 

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. EEO is the Law: https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf

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