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Documentation Specialist (Clinical)

Legacy Health Type Full time Posted 7/12/2014
Salary - n/a - Starts 9/17/2014
OR - Oregon (All) - Portland Referral - n/a -    
Job Title:  Documentation Specialist (Clinical)
Work Location:  Emanuel Medical Ctr campus - N Portland OR
Department:  Care Management
Shift:  Day
Status:  Full time benefited, 36-40 hrs/wk
Budgeted Hrs/Wk:  40
Hours:  8-4:30
Work Days:  Mon-Fri, no weekends
Job Number:  14-1639
Salary Min:  29.07
Salary Max:  43.31
Shift Differentials:  
Bonus/Relo Eligible:  
Critical To Fill:  
Union:  Non-union
Job Code:  05055
Job Description: 



The Documentation Specialist coordinates the documentation improvement program by evaluating the quality of clinical documentation for incomplete or inconsistent documentation for inpatient encounters, communicating with and training physicians regarding documentation, and maintaining data to monitor and report on progress of the program. This activity supports the appropriate clinical picture and level of severity of the patient, while providing accurate and complete information utilized in the profiling and outcomes reporting of the hospital and the physicians. This position interacts extensively with physicians and health care team members and is responsible for facilitating modifications to the overall quality and completeness of the medical record documentation.

Job Qualifications: 




BA/BS degree in a related healthcare field or equivalent experience OR graduate from an accredited Health Information Technology/Health Information Administration program required.




Minimum of 5 years of experience in an acute care clinical setting OR minimum of 5 years coding experience in an acute care setting required. Background showing high level of clinical proficiency required. Experience in compliance management or other management/supervisory experience preferred. Experience and knowledge of quality outcomes in a patient care environment preferred. Experience conducting efficient and regular documentation reviews preferred.



RHIT or RHIA with CCS preferred.

RN, LVN, CSW or other equivalent license/certification preferred.


Strong communication and negotiating skills adaptable to a wide variety of interpersonal encounters with the entire healthcare team and outside auditors.

Strong organizational skills with demonstrated leadership ability.

Demonstrated and highly developed problem solving skills and self-directed, motivated behavior.

Demonstrated ability to develop and maintain supportive, collaborative relationships with physicians.

Strong computer/PC skills essential, including Excel, PowerPoint, and multiple technical systems.

Detail oriented.

Working knowledge with Joint Commission, State and Medicare Standards.

Working knowledge of ICD-9-CM coding and MS-DRG’s.

Ability to analyze complex clinical scenarios and apply critical thinking. 

Supports and models Legacy's preferred Employee profile.