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Job Details

Clinical Documentation Specialist 40hrs

Company name
Houston Northwest Medical Center

Worcester, MA

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Description: POSITION PURPOSE:Responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and documents findings. Facilitates modifications to clinical documentation to ensure completeness through extensive interaction with physicians or medical staff departments. Serves as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of documentation. Reports results of audits to departments and committees. Identifies opportunities for interdepartmental and interdepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities. INTERPERSONAL RELATIONSHIPS:Excellent written and verbal communication skills, critical thinking skills and interpersonal skills to build effective partnering relationships with physicians, care management team, nursing staff, coding staff and hospital staff.\u00a0 Qualifications: EDUCATIONAL REQUIREMENTS:Graduate of an approved Health Information Technology\/ Management program with credentials of RHIA, RHIA eligible, RHIT, RHIT eligible, CCS, CCS-P and \/or graduate from an accredited nursing program with LPN or RN licensure. PHYSICAL REQUIREMENTS:Ability to move throughout the department, hospital and other Saint Vincent Hospital locations. Visual skills, motor skills and the dexterity to operate a PC, fax, copy machine and telephones. Able to lift 25 pounds unassisted.EXPERIENCE REQUIRED:Two years of experience in acute care setting. Knowledge of care delivery documentation systems and related medical record documents. Computer skills and familiarity with basic office equipment required. Exposure to MS DRG coding classification preferred. SUPERVISORY RESPONSIBILITIES:None. PROFESSIONAL LICENSURE AND CERTIFICATION REQUIRED:RHIA, RHIA eligible, or RHIT, RHIT eligible, or CCS, CCS-P,or RN, LPN licensureREPORTING RELATIONSHIPS AND LEVEL OF AUTONOMY:Directly reports to the Director of Health Information Management and collaborates closely the Coding Manager. Job: Medical RecordsPrimary Location: Worcester, MassachusettsFacility: Saint Vincent HospitalJob Type: Full-timeShift Type: Days Employment practices will not be influenced or affected by an applicant\u2019s or employee\u2019s 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. Tenet participates in the E-Verify program. Follow the link below for additional information. E-Verify:

Company info

Houston Northwest Medical Center
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Company Profile
The employees, medical staff, and volunteers at Houston Northwest Medical Center understand the true nature of what is meant by, “it is better to give than to receive.” We know the spirit of giving is one of life’s greatest rewards and we share this gift each and every day without hesitation as we care for the men, women, and children of our community. We have become deeply rooted in the community we serve by providing quality health care, offering numerous educational classes and screenings, and participating in many local events.

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