Clinical Documentation Specialist - Whitesburg

Appalachian Regional Healthcare (ARH); Hazard (KY); Presencial; USD 60.000 - 80.000; Tempo integral

Resumo da vaga

Appalachian Regional Healthcare (ARH) seeks a Documentation Specialist to evaluate medical records for compliance with state and federal regulations and provide consultative support to medical records staff, physicians, and other staff. Reports to System Director, MPAS, Community CEO’s or MPAS designee; no supervision.

Responsibilities include evaluating quality of medical record systems, reviewing patient charts, advising physicians on regulatory impacts, and coordinating with facility

Qualificações

• Graduate from an accredited School of Nursing.
• Current nursing licensure in the state of employment.
• Strong knowledge of clinical documentation and coding principles.
• Ability to review and analyze medical records for accuracy and completeness.

Responsabilidades

• Evaluate the quality of medical record systems to ensure regulatory compliance.
• Review patient chart documentation for compliance with standards and regulations.
• Consult with physicians on new regulations and required actions.
• Advise administrators and staff on corrective measures for compliance.
• Maintain liaison with state, federal, and local organizations on standards.
• Perform chart reviews when patient status changes to assure correct payments.
• Interviews with staff to gather information on policies and procedures.

Conhecimentos

Clinical documentation

Regulatory compliance

Medical records review

Interpersonal communication

Analysis and problem-solving

Confidentiality

Formação

Graduate from an accredited School of Nursing

Descrição da vaga

The Documentation Specialist evaluates the medical records to ascertain the degree of documentation compliance with State and Federal regulations; and provides consultative services to the medical records staff, physicians, and other pertinent staff. The Documentation Specialist reports to the System Director, MPAS, Community CEO’s or MPAS designee and does not supervise anyone. This position has frequent contact with the System Compliance Department, Administrators, physicians, medical records, State and Federal agencies, various Department Heads, and nursing staff.

The Documentation Specialist evaluates the medical records to ascertain the degree of documentation compliance with State and Federal regulations; and provides consultative services to the medical records staff, physicians, and other pertinent staff. The Documentation Specialist reports to the System Director, MPAS, Community CEO’s or MPAS designee and does not supervise anyone. This position has frequent contact with the System Compliance Department, Administrators, physicians, medical records, State and Federal agencies, various Department Heads, and nursing staff.

Responsibilities

• Evaluates the quality of medical record systems in the system to determine that the service is in compliance with State and Federal regulations and medical records standards.
• Reviews patient chart documentation for compliance with professional medical records standards and practices and for State and Federal regulations.
• Provides consultation to physicians concerning new State and Federal regulations; advises them on the impact upon medical records services and actions required for implementation and compliance.
• Consults with facility administrators and their medical records staff to provide them with interpretations of State and Federal regulations; advises them on appropriate corrective measures for compliance.
• Maintains liaison with various State, Federal, and local organizations regarding the development, definition, and administration of medical records standards and practices.
• Review patients' records to ascertain if appropriate type and quality of care was given according to established criteria for the diagnosis.
• Performs retrospective chart review of patients who have a change of status to assure that necessary payment status is changed.
• Visits system facilities and interviews administrators, nursing staff and medical records staff to obtain information regarding policies and procedures.
• Reviews and evaluates policies and procedures to determine that they are in writing and meet the requirements of the various regulations.
• May investigate complaints regarding medical records services and prepare reports of the findings.
• Perform other related duties within the scope of the job classification.

Qualifications

Education

• Graduate from an accredited School of Nursing required.

Licenses & Certifications

• Current nursing licensure in the state of employment required.

Required Skills, Knowledge & Abilities

• Possess a high degree of clinical documentation knowledge to support coding activities, medical record reviews, and physician documentation requirements.
• Knowledge of clinical documentation improvement principles and healthcare documentation standards.
• Ability to review, interpret, and analyze medical records for accuracy and completeness.
• Possess exceptional human relations skills.
• Ability to work constructively and effectively on a one-to-one basis with physicians, nursing staff, department heads, administrative personnel, health information personnel, patients, and representatives of government or third-party agencies.
• Strong verbal and written communication skills.
• Ability to educate and collaborate with providers regarding documentation requirements and coding opportunities.
• Strong organizational, analytical, and problem-solving skills.
• Ability to maintain confidentiality and handle sensitive patient information appropriately.