RN, Registered Nurse Clinical Documentation Specialist - Clinical Information

Location
Lake Charles, LA
Salary
Competitive
Posted
Feb 12, 2020
Closes
Mar 09, 2020
Specialty
Med / Surg
Contract Type
Permanent
Hours
Full Time
Description
The Clinical Documentation Specialist is responsible for facilitation improvement in the overall quality and completeness of the medical record documentation. Obtains appropriate documentation through extensive interaction with physicians, nursing staff, other patient caregivers and health information management coding staff to ensure that reimbursement if received for the level of services rendered to the patients and that the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Requirements
  • RN; BSN preferred
  • Basic computer skills in word processing and spreadsheet utilization.
  • Excellent written and verbal communication skills.
  • Proficient in computer use (desktop and/or laptop).
  • Demonstrates basic knowledge regarding HIM coding standards.
  • Analytic skills necessary to accurately assess patient medical records.
  • Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes.
  • Ability to walk and stand 80% of work time.
  • Ability to be flexible and adjust to workload/assignment changes and interruptions.
  • Healthstream (HLC) modules completed by assigned date.
  • Complete Associate Self-evaluation and give to Supervisor by assigned date.
  • Attend 2 of the Associate Round Tables per fiscal year.
  • Minimum of 5 years recent experience in an acute care setting in a clinical nursing field required.
  • Prior experience in clinical documentation improvement, utilization review/management, discharge planning, quality management, case management or coding preferred.
  • Licensed as a Registered Nurse in the State of Louisiana
  • CPR required

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