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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
Description:

Opportunities include Brookwood Baptist Medical Center (Birmingham) and Citizens Baptist Medical Center (Talladega)

Summary

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.

Responsibilities Include:

  • 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

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Qualifications:

Education

Required: Graduate of an accredited school of nursing, AHIMA accredited school, United States or international school of medicine

Experience

Required: 0-2 years of CDS experience and 2 years recent acute care experience in a clinical or inpatient coding setting

Certifications

Required: RN, LVN, LPN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP*

Job: Nursing
Primary Location: Birmingham, Alabama
Facility: Brookwood Medical Center
Job Type: Full-time
Shift Type: Days

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

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