Job Description

Job Description

Position Summary

Sovah Health is looking for the ideal candidate who will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.

· Improves overall quality and completeness of clinical documentation by performing admission / continued stay reviews

· 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

· Will utilize coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation user for measuring and reporting physician and hospital outcomes.

· Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines and clinical expertise.

· Tracks and trends specific opportunities for improvement through the query process

· Conducts educational sessions with physicians and other health care team members on documentation requirements.

· Reviews clinical issues with physician advisors.

· Participates in data collection for performance measures.

· Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and ICD-9-CM Official Guidelines for Coding and Reporting.

· Participates in department and facility Quality and Performance initiatives.

· Works closely with case management, quality management, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics.

· Works in conjunction with the Directors of Quality Improvement, Medical Staff Credentialing and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement.

· Prepares and presents educational programs using adult learning principles for identified improvement needs as indicated.

· Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans

Who We Are:

People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Licensed for 220 beds, SOVAH Health – Martinsville, is a full service, acute-care hospital providing over 22 medical specialties. Among the services we offer are a home health & hospice agency, advanced wound healing center, cardiac rehabilitation center, two cardiac catheterization labs, and medical & radiation oncology services.

Where We Are:

In Martinsville, explore culture and arts, enjoy kayaking or hiking and so much more in the foothills of the Blue Ridge Mountains. From the river to the racetrack, we offer plenty of activities to guarantee that you and your family have a fun filled time!

Why Choose Us:

· Health (Medical, Dental, Vision) and 401K Benefits for full-time employees

· Competitive Paid Time Off / Extended Illness Bank package for full-time employees

· Employee Assistance Program – mental, physical, and financial wellness assistance

· Tuition Reimbursement/Assistance for qualified applicants

· Professional development, Growth opportunities, and Mentor-based training

· And much more…

Minimum Qualifications

Minimum Education

High school diploma or equivalent required, Degree in Nursing preferred. Additional Healthcare associated degree & education will be considered.

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.

Licenses:

Licensed as a Registered Nurse in the Commonwealth of Virginia or compact state.

Certifications:

One of the following required if not an RN:

Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDI

Licensed Registered Nurse or LPN

Additional Healthcare Certifications considered

Certified Professional Coder-Hospital (CPC-H)

Certified Coding Associate (CCA)Registered Health Information Technician (RHIT)Registered Health Information Administrator (RHIA)Additional Coding Certificates will be taken under consideration (AAPC)

Minimum Work Experience2 years hospital experience

Prior experience in clinical documentation improvement and/or coding accuracy preferred.

EEOC Statement:

SOVAH Health - Martinsville is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.

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