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Clinical Documentation Specialist

Location: Rochester, New York
Job # 2410595
Date Posted: 05-30-2013
Major acute care facility in Western New York State has immediate, full time openings for 2 Clinical Documentation Specialists as follows:

*Clinical Documentation Specialist:  RN (NY License) and 5 years clinical experience (acute care, utilization review, etc.) plus RHIT/RHIA, CCS or CCDS (preferred). Must obtain CCDS within one year of hire.

*Clinical Documentation Specialist: Minimum 5 years inpatient coding experience, RHIT/RHIA, CCS or CCDS (preferred). CCS must obtain CCDS within one year.

CDS facilitates and obtains documentation related to clinical conditions or procedures on support of determination of severity of illness, expected mortality risk and complexity of patient care.

Provides daily clinical evaluation of medical records and documentation b\y the medical staff and healthcare team to include physician documentation, clinical documentation, lab results, diagnostic information and treatment plans per applicable policies and procedures.

Communicate with physicians and healthcare team members as needed to obtain missing information and documentation and clarify unclear or conflicting information to insure accurate and complete medical record content.
  • Must have advanced clinical expertise and knowledge of complex disease processes with broad experience in an inpatient environment.
  • Must have coding familiarity/experience in a hospital setting performing inpatient coding utilizing the AP DRG and the Medicare DRG system.
  • Must be knowledgeable in federal, state and private payer regulations.
  • Candidates must have RN/NY License & 5 years clinical experience plus RHIT/RHIA, CCS or CCDS (preferred) OR
  • Minimum 5 years inpatient coding experience plus RHIT/RHIA, CCS or CCDS (preferred). In both cases, CCS must obtain CCDS within one year of hire.
  • Clean drug screen/criminal record
  • US Residents only
  • Availability to work on-site, full time.
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