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CLINICAL DOCUMENTATION SPECIALIST RN

Company name
St. Luke's Hospital

Location
Chesterfield, MO

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Description Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Plays a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting quality of care outcomes.\u00a0 Principle Accountablilties: 1. Collaborates with physicians, physician extender, nurse, case manager and Health Information Management coder to identify areas for improved physician documentation. 2. Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings on worksheets, denoting all key information utilized in the tracking process.\u00a0 3. Clarifies documentation in the records utilizing assertive communication skills to guide physician, case manager, or other healthcare professionals to make changes as appropriate to clarify documentation.\u00a0 4. Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality in compliance with all guidelines and requirements. 5. Responds to physicians queries. 6. Enters working DRGs into the computerized clinical documentation system. 7. Utilizes monitoring tools, reports and data to track progress. 8. Communicates findings with appropriate management staff and \/or providers. 9. Identifies the need for clinical documentation through report analysis. 10.\u00a0Assists in the development of physician query response reports. 11. Provides education and in-service as necessary to physicians and staff. 12. Maintains high productivity. 13. Performs efficiently regardless of flucutation in work volume. 14. Contributes to department quality improvement and follows organizational quality customer service philosophy. 15. Flexible and creative on new approaches to improve performance. 16. All other duties as assigned . Education Graduate of a school of Nursing, AHIMA accredited school, or international medical school Currently licensed as a Registered Nurse or Licensed Practical Nurse in the State of Missouri; or is RHIA, RHIT, or CCS credentialed Experience Minimum of three years clinical or inpatient coding experience in an acute care setting required; 5 years experience strongly preferred. Knowledge of care delivery documentation systems and related medical record documents. Knowledge of age-specific needs and the elements of disease process and related procedures. Strong broad-based clinical knowledge and understanding of pathology\/physiology of disease process.\u00a0 Excellent written and verbal communication skills.\u00a0 Excellent critical thinking skills.\u00a0 Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff and Health Information systems coding staff. Computer literacy and familiarity with the operation of basic office equipment. Assertive personality traits to facilitate ongoing physician communication. Ability to work independently in a time sensitive environment.\u00a0 Working knowledge of Medicare reimbursement system and coding structures\/national coding guidelines. Working Conditions \u00a0Fast paced environment requiring the ability to plan and problem solve with specific time frames and periods of high stress.\u00a0 \u00a0Exposure to chemicals and blood borne pathogens that require personal protective equipment. Mission\/Values Faithful to our Episcopal-Presbyterian heritage and its ministry of healing, St. Luke's is dedicated to improving the health of the community. Using talents and resources responsibly, our medical staff, employees and volunteers provide care for the whole person with compassion, professional excellence, and respect for each other and those we serve. Core Values: Human Dignity, Compassion, Justice, Excellence, and Stewardship. Human Dignity: We accept and treat all persons as being created in the image of God. Compassion: We respond with caring to the needs of others as if they were members of our family. Justice: We honor each person's rights and responsibilities in light of the common good. Excellence: We set and strive to attain high standards of performance and continuous improvement. Stewardship: We use our talents and resources wisely, with honesty and integrity. FACES - Friendly - Available - Caring - Efficient - Safe Communication Standards: Promotes and provides courteous and effective communication with internal and external customers.

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St. Luke's Hospital

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