Clinical Documentation Specialist — Acute Care

Prime Healthcare; Reno, Northern (NV, KY); Híbrido; USD 80.000 - 110.000; Jornada completa

Descripción de la vacante

Saint Mary’s Health Network in Reno, NV is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring documentation reflects quality of care and supports appropriate reimbursement. You will collaborate with physicians and staff to optimize documentation and admissions criteria, while maintaining current clinical standards.

Ideal candidates hold a medical graduate, PA, or nursing degree, with acute care experience and strong

Formación

• Medical Graduate, PA or Nursing Graduate required.
• Minimum of three one (1+) year’s clinical experience in an acute care setting.
• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written, and verbal communication skills and critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• ECFMG Certificate or RN license preferred.
• Prior Case Management Experience preferred.
• Working knowledge of the Medicare reimbursement system and coding structures preferred.
• Current BCLS (AHA) certificate upon hire and maintain current preferred.
• ACLS Certificate preferred.

Responsabilidades

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate whether the clinical documentation reflects quality-of-care outcomes and reimbursement compliance for acute care services.
• Work closely with the medical staff to facilitate appropriate clinical documentation of patient care.
• Perform documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings.
• Perform other duties as assigned or required.

Conocimientos

Clinical documentation

Communication skills

Critical thinking

Interpersonal skills

Independence

Educación

Medical Graduate, PA or Nursing Graduate

ECFMG/RN license preferred

Descripción del empleo

Saint Mary’s Health Network in Reno, NV is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring documentation reflects quality of care and supports appropriate reimbursement. You will collaborate with physicians and staff to optimize documentation and admissions criteria, while maintaining current clinical standards.

Ideal candidates hold a medical graduate, PA, or nursing degree, with acute care experience and strong