Clinical Documentation Specialist - Anderson, United States - AnMed

Description

This position is responsible for performing concurrent review of the clinical documentation in the medical record within the Clinical Effectiveness program at AnMed.

These duties include but are not limited to:

queries to the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality; thorough chart review to identify comorbidities/complications, and documents these appropriately on the documentation worksheet.

Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.

Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization. Maintains the ability to be flexible, and prioritizes daily responsibilities.

Qualifications: Minimum of three to five years of clinical experience required with current SC license as RN. Excellent communication and critical thinking skills. Computer experience required. Ability to work independently and meet deadlines and schedules is required. 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. Working knowledge of Medicare reimbursement system, coding structures, medical necessity criteria preferred, but not required.