Clinical Documentation Specialist- Inpatient- LOCATION: Phoenixville Hospital

Responsibilities Provide clinically based, daily, concurrent and retrospective review of inpatient medical records. Facilitation of appropriate provider documentation of patient care to accurately reflect severity of illness, intensity of service and risk of mortality. Works collaboratively with the Providers and Coding staff to provide physician and staff education related to clinical documentation. Knowledgeable of Federal, State and other payer regulations and requirements that will impact documentation. Knowledge of the Medicare query guidelines. Responsible to interact with the providers both verbally and in writing to obtain appropriate documentation clarification in the Medical Record. Knowledge of the ICD 10 CM Coding guidelines and rule. Obtain accurate and compliant documentation by providers for reimbursement for acute care services and in reporting quality outcomes.

Qualifications

Education Requirements

• Post High School Diploma Program or combination of relevant education & experience may be considered in lieu of Post High School Diploma Program

Experience

• Relevant Experience

Certification and Licensure

• CCDS or CDIP (required after 2 years in job)
• RN or LPN (if Nursing background)
• AHIMA Clinical Coding Specialist CCS (if coding background)
• DO, MD, NP, PA (if provider background)
• AAPC Certified Professional Coder (if outpatient coding background)

Required Skills

• Collaborative Skills
• Detail Oriented
• Excellent Communications Skills
• Excellent Interpersonal Skills
• Excellent Teamwork Skills
• General Clerical Skills
• Keyboarding
• Microsoft Excel
• Microsoft PowerPoint
• Microsoft Word
• Organizational Skills