Clinical Documentation Specialist

Silver Cross Hospital is an extraordinary place to work. We’re known for our culture of excellence and delivery of unrivaled experiences for our patients, their families, the communities we serve…and for each other. Come join us! It’s the way you want to be treated.

Position Title:Clinical Documentation Specialist

Position Summary: To assist the hospital in achieving compliant, clear, complete, concise, concurrent documentation to support quality care and efficient and thorough post discharge coding for accurate classification and receipt of legitimate reimbursement optimization as well as to mitigate risk within the legal health record.

Essential Duties and Responsibilities:
• Provides concurrent review of clinical documentation in medical records
• Queries medical staff and other caregivers as necessary to obtain accurate and complete documentation that supports severity of patient illness and risk of mortality
• Performs a thorough chart review to identify co morbidities/complication, and documents these appropriately within the concurrent DRG worksheet
• Demonstrates and understands the importance of and make an effort to capture all appropriate secondary diagnoses for quality rating/proofing purposes
• Provides feedback to medicals staff and conduct education
• Promotes a clean and safe environment of care, utilizing the SAFE error prevention habits
• Provides the highest standard of privacy and confidentiality in matters involving patients, coworkers, and the hospital by abiding by the Standards of Conduct

Required Qualifications:
Education and Training:
• A minimum of a bachelor’s degree plus an RHIA®, RHIT®, CCS®, CCS-P®, RN, LVN, MD or DO and two (2) years of experience in clinical documentation improvement or inpatient coding OR
• A minimum of a bachelor’s degree (or equivalent education) in an allied health field and three (3) years of experience in clinical documentation improvement or inpatient coding. The education component must include completed coursework in medical terminology and anatomy and physiology.
• Excellent verbal, written, presentation, computer and interpersonal communication skills.
• CCDS and/or CDIP Certification is ideal.
• Highly Desired: ICD-10-CM/PCS Coding training and certification (may be provided on job)

Work Shift Details:

Department:

Benefits for You

At Silver Cross Hospital, we care about your health and well-being and that is why we work hard to provide quality and affordable benefit options for you and your eligible family members.

Silver Cross Hospital and Silver Cross Medical Groups offer a comprehensive benefit package available for Full-time and Part-time employees which includes:

· Medical, Dental and Vision plans

· Life Insurance

· Flexible Spending Account

· Other voluntary benefit plans

· PTO and Sick time

· 401(k) plan with a match

· Wellness program

· Tuition Reimbursement

Registry employees who meet eligibility may participate in our 401(k) Savings plan with a potential match. However,registry employees are ineligible for Health and Welfare benefits.

The final pay rate offered may be more than the posted range based on several factors including but not limited to: licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more.

The expected pay for this position is listed below: