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CLINICAL DOCUMENTATION SPEC II - Clinical Documentation Impvmnt

Apply Job ID 38979 Job Status Full Time Shift 1

More information about this job:


Short Description:


Responsible for ensuring the overall quality and completeness of medical record documentation.

Facilitates modifications to clinical documentation through concurrent interaction with

physicians, nursing staff, other patient caregiver and Health Information coding staff to

support that appropriate reimbursement and clinical severity is captured for the level of

service rendered to all inpatients.

Supports timely, accurate and complete documentation of clinical information used for

measuring and reporting physician and hospital outcomes.

Educates all members of the patient care team on an ongoing basis.

Professional team player, able to communicated well with others on all levels.

Regular significant contacts with other personnel throughout and outside the hospital.

Contacts may be in person, by telephone or through e-mail correspondence.

Flexible with a working knowledge of all areas of adult medicine.

Occasional lifting/carrying up to fifteen pounds, as well as reaching, stretching, stooping,

bending, kneeling, crouching, standing, walking and pushing/pulling to move and file

medical records alone or in carts.

Ability to sit for very long periods of time, manual dexterity and mobility for extensive use of

computer screen, keyboard, copy and facsimile machines, reader/printer and other office

equipment.

Adequate to perform essential functions of the job with the type of judgments and potential

consequences outlined above.

Special Requirements:


Scheduled Days / Hours: .; License (or Certification):NJ-RN Required

RN, BSN

EPIC, JATA GUIDE software, 2 years minimum experience as Clinical Documentation Specialist in an acute setting.

Mandatory, no exceptions: CCDS, or CCS, or CDIP; Registered nurse – any state

Essential mental abilities: excellent critical thinking skills, able to assess, evaluate and teach. Must be self governed, disciplined, and organized.

Requires excellent work ethic, analytical thinking, problem solving, excellent computer skills, excellent verbal and written communication with knowledge of email etiquette . Must be proficient in Word, Excel, PowerPoint and typing (60 WPM)

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