Clinical Documentation Specialist - HIM/Medical Records Opportunities include Brookwood BMC, Shelby BMC and Citizens BMC $2500 Sign On Bonus for Qualified RN, LPN, RHIT, RHIA, CCS, and CIC Professionals
- Job ID 2105001544
- Date posted 01/15/2021
- Facility Brookwood Baptist Medical Center
Opportunities include Brookwood Baptist Medical Center (Birmingham) and Citizens Baptist Medical Center (Talladega)
Analyzes the clinical status of the patient, current treatment plan and other portions of the medical record, on admission and throughout hospitalization; tracks progress of documentation improvement and works collaboratively with the healthcare team to facilitate documentation within the medical record that accurately and thoroughly reflects the patients' condition/severity, services rendered and resources used.
- Communicates with physicians to validate observations and suggest additional and/or the need for more specific information
- Works closely with healthcare team and coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care
- Conducts initial and extended stay concurrent reviews
- Monitors documentation for compliance with core measures
Required: Graduate of an accredited school of nursing, AHIMA accredited school, United States or international school of medicine
Required: 0-2 years of CDS experience and 2 years recent acute care experience in a clinical or inpatient coding setting
Required: RN, LVN, LPN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP*
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