Clinical Documentation Specialist - Whitesburg

Responsibilities

• Evaluates the quality of medical record systems in the system to determine that the service is in compliance with State and Federal regulations and medical records standards.
• Reviews patient chart documentation for compliance with professional medical records standards and practices and for State and Federal regulations.
• Provides consultation to physicians concerning new State and Federal regulations; advises them on the impact upon medical records services and actions required for implementation and compliance.
• Consults with facility administrators and their medical records staff to provide them with interpretations of State and Federal regulations; advises them on appropriate corrective measures for compliance.
• Maintains liaison with various State, Federal, and local organizations regarding the development, definition, and administration of medical records standards and practices.
• Reviews and evaluates policies and procedures to determine that they are in writing and meet the requirements of the various regulations.
• Performs retrospective chart review of patients who have a change of status to assure that necessary payment status is changed.
• Visits system facilities and interviews administrators, nursing staff and medical records staff to obtain information regarding policies and procedures.
• Investigates complaints regarding medical records services and prepares reports of the findings.

Qualifications

• Graduate from an accredited School of Nursing with current licensure in state of employment.
• Possess a high degree of clinical documentation knowledge to support coding, review of medical records, and physicians.
• Possess a high degree of skill in human relations with ability to deal constructively on a one-to-one basis with physicians, nursing staff, department heads, administrative personnel, health information personnel, patients, and representatives of government or third party agencies.