Coord, Clinical Documentation

BJC HealthCare is one of the largest nonprofit health care organizations in the United States, delivering services to residents primarily in the greater St. Louis, southern Illinois and southeast Missouri regions. With net revenues of $6.3 billion and more than 30,000 employees, BJC serves patients and their families in urban, suburban and rural communities through its 14 hospitals and multiple community health locations. Services include inpatient and outpatient care, primary care, community health and wellness, workplace health, home health, community mental health, rehabilitation, long-term care and hospice.

About the role

The Clinical Documentation Coordinator (Audit) reviews, audits, collects, and compiles data related to medical record documentation to ensure compliance with Federal and State regulatory requirements. This role involves handling specialty audits by gathering charts for denials, reviewing them, and sending additional documentation as needed. The coordinator ensures the integrity of the medical record and that clinical documentation is thoroughly and timely recorded. They also provide feedback and direction on new audit workflows to support areas identified via regulatory survey action plans or compliance gaps.

Responsibilities

• Reviews and audits medical record documentation against Federal and State regulatory compliance requirements, interpreting compliance of documentation with required standards.
• Accurately collects and compiles data in support of regulatory survey action plans, hospital audit requirements, and clinical documentation-related requests for information for executive-level reporting.
• Assists Clinical Documentation Specialists in ensuring the integrity of the medical record accurately reflects clinical documentation.
• Maintains and collaborates to complete the collection of clinical documentation data to support timely reporting to Regulatory Teams, Hospital Leadership, and other applicable teams focused on ensuring compliant clinical documentation.
• Compiles charts in EPIC and handles specialty audits, including gathering charts for denials and reviewing them to send additional documentation as needed.

Requirements

• High School Diploma or GED (required).
• Associate degree or trade school equivalent (preferred).
• 2-5 years of experience in a related field (preferred).
• Experience working with medical records (ideal).
• Registered Health Information Technician (RHIT) certification (preferred).

Benefits

• Comprehensive medical, dental, vision, life insurance, and legal services available on the first day of the month after hire.
• Disability insurance paid for by BJC.
• Annual 4% BJC Automatic Retirement Contribution.
• 401(k) plan with BJC match.
• Tuition Assistance available from the first day.
• BJC Institute for Learning and Development.
• Health Care and Dependent Care Flexible Spending Accounts.
• Paid Time Off benefit combining vacation, sick days, holidays, and personal time.
• Adoption assistance.