Clinical Documentation Specialist at tgmctest – Houma, Louisiana

Clinical Documentation Specialist

The Clinical Documentation Specialist is responsible for ensuring that clinical documentation within the health system accurately reflects the services and care provided to patients and is consistent with the criteria for high quality clinical documentation. The Specialist acts as a coordinator of physician clinical documentation, coding, reimbursement processes in working towards agreed upon quality and productivity targets for all services in the system. The Clinical Documentation Specialist identifies monitors, and reports opportunities for quality and performance improvement to the appropriate department. The Clinical Documentation Specialist takes an active role in performance improvement activities as it relates to documentations improvement.

Qualifications:

1. ICD-9CM hospital based coding experience preferred
2. Credentialed as an RN or LPN or PA or NP or RHIA or RHIT, or CCS required
3. CCM or CPHQ certification preferred
4. Critical care or strong medical/surgical background required or surgical background if assigned to surgical areas; 3-5 years in clinical practice preferred
5. Familiar with government health care reimbursement systems
6. Have experience working collaboratively with diverse groups in a health care environment
7. Be successful in interacting effectively with physicians - verbal and written
8. Basic computer literacy is required; experience with Windows, word processing, spreadsheets, graphics, and databases is preferred
9. Ability to analyze large amounts of data to identify trends
10. Experience with writing technical reports is desirable