The Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation selected hospitals. Reports to the District Director of Case Management.. Performs concurrent record reviews on all selected admissions and documents findings-this may be done both onsite and/or through the electronic medical record. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, care management, nursing staff, other patient care givers and medical record coding staff. Serves as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality and final code assignment. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals. Reports concurrent chart review and query outcomes to hospital departments and committees at designated intervals. Maintains accurate records of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Identifies opportunities for intradepartmental and interdepartmental operational improvements.
Contact:
Abe Ghebrehiwet
Senior Account Executive
Nurse Resolutions
888.411.2228. Toll Free
407.341.9647. Cell
407.557.2270. Fax
www.NurseResolutions.com
Abe@NurseResolutions.com
Location: Las Vegas, NV 89119
Compensation: Depends on experience
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nevada