Clinical Documentation Specialist, Health Information Management
North Mississippi Health Services, Tupelo, MS, United States
Clinical Documentation
Facilitates clinical documentation improvement through extensive daily interaction with physicians, caregivers, case management, and HIM Coding staff to achieve timely, accurate, and complete medical record documentation
Provides concurrent clinical and analytical evaluation of medical records to ensure that the documentation supports the appropriate severity of illness, expected risk of mortality, and complexity of care provided
Performs post-discharge quality audits of select medical records to ensure documentation supports DRG assignment, appropriate severity of illness, expected risk of mortality, and complexity of care provided
Support timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes
Education/Training
Provides on‑going education to all members of the patient care team regarding high‑quality clinical documentation guidelines, medical terminology and practices
Initiates and participates in program related meetings, healthcare providers education, staff development, departmental activities, and in‑service opportunities
Reporting
Formulate appropriate physician queries when records are not accurate or complete
Maintains an accurate and complete record review in compliance with departmental and regulatory guidelines
Liaison
Serves as a resource for providers and HIS coding staff
Regulatory
Adheres to NMHS/NMMC Policies/Procedures/Guidelines
Complies with applicable Local/State/Federal procedures, guidelines, regulations and laws
Requirements
Bachelor’s Degree in Nursing or related field; required
Current licensed as a Registered Nurse in the State of Mississippi; required
Minimum of 3 years clinical experience in an Acute Care setting; required
Knowledge of care delivery documentation system and related medical records documents; required
Excellent critical thinking and communication (written and verbal) skills; required
Strong broad‑based clinical knowledge and understanding of pathology/physiology of disease processes; required
Working knowledge of Medicare reimbursement and ICD-9/ICD-10 coding / terminology; preferred
Computer experience for data input/retrieval; required
Excellent interpersonal skills; required
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Facilitates clinical documentation improvement through extensive daily interaction with physicians, caregivers, case management, and HIM Coding staff to achieve timely, accurate, and complete medical record documentation
Provides concurrent clinical and analytical evaluation of medical records to ensure that the documentation supports the appropriate severity of illness, expected risk of mortality, and complexity of care provided
Performs post-discharge quality audits of select medical records to ensure documentation supports DRG assignment, appropriate severity of illness, expected risk of mortality, and complexity of care provided
Support timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes
Education/Training
Provides on‑going education to all members of the patient care team regarding high‑quality clinical documentation guidelines, medical terminology and practices
Initiates and participates in program related meetings, healthcare providers education, staff development, departmental activities, and in‑service opportunities
Reporting
Formulate appropriate physician queries when records are not accurate or complete
Maintains an accurate and complete record review in compliance with departmental and regulatory guidelines
Liaison
Serves as a resource for providers and HIS coding staff
Regulatory
Adheres to NMHS/NMMC Policies/Procedures/Guidelines
Complies with applicable Local/State/Federal procedures, guidelines, regulations and laws
Requirements
Bachelor’s Degree in Nursing or related field; required
Current licensed as a Registered Nurse in the State of Mississippi; required
Minimum of 3 years clinical experience in an Acute Care setting; required
Knowledge of care delivery documentation system and related medical records documents; required
Excellent critical thinking and communication (written and verbal) skills; required
Strong broad‑based clinical knowledge and understanding of pathology/physiology of disease processes; required
Working knowledge of Medicare reimbursement and ICD-9/ICD-10 coding / terminology; preferred
Computer experience for data input/retrieval; required
Excellent interpersonal skills; required
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