Coder/Clin Document Spec - Health Information Management - FT - Days
Company: Haywood Regional Medical Center
Location: Clyde
Posted on: April 17, 2024
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Job Description:
Conducts daily reviews of inpatient medical records to identify
missing, vague, and/or incomplete diagnoses and procedures.
Conducts timely follow-up reviews of clinical documentation to
ensure that issues discussed and queries left in the medical record
have been answered by the provider.
Utilizes coding and clinical expertise to identify opportunities
and ensure the accuracy and completeness of clinical documentation
used for measuring and reporting physician and hospital
outcomes.
Queries physicians on specificity of procedures performed and
diagnoses based on accepted coding guidelines, clinical expertise
and LifePoint Hospitals query policy.
Tracks and trends specific opportunities for CDI process
improvement through the utilization of metrics reports.
Conducts educational sessions with physicians and other health care
team members on documentation requirements.
Prepares and presents educational programs to all internal
constituents related to clinical documentation issues and
coordinates same with clinical staff, physicians, compliance and
coding staff.
Makes regular reports of progress toward goals associated with
clinical documentation improvement opportunities and operational
improvement plans.
Assumes responsibilities for following compliance guidelines with
federal, state, and local regulations within the department.
Minimum Education
Bachelor's Degree Preferred
Required Skills
Requires critical thinking skills, decisive judgment and the
ability to work with minimal supervision. Must be able to work in a
stressful environment and take appropriate action.
Required Skills
Licenses:
Licensed Registered Nurse (RN), Licensed Practical Nurse (LPN),
CCS, RHIA, RHIT, or combination thereof Required.
Equal opportunity and affirmative action employers and are looking
for diversity in candidates for employment:
Minority/Female/Disabled/Protected Veteran
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Keywords: Haywood Regional Medical Center, Asheville , Coder/Clin Document Spec - Health Information Management - FT - Days, Executive , Clyde, North Carolina
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