Clinical Documentation Specialist | Mon-Friday 8a-4:30p

Conducts concurrent and retrospective review of the clinical documentation in the medical record to achieve the highest level of specificity and accuracy before final coding and billing. Facilitates the appropriate physician documentation for any clinical conditions or procedures through the examination and querying of documentation of all conditions, treatments and procedures to ensure the highest level of care given. Assists the physician in identifying and documenting the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient which will in turn improve the quality of patient care, more accurately portray the facility's quality outcomes ratings, reduce compliance risks, and capture appropriate reimbursement. Facilitates modifications to clinical documentation through extensive concurrent interaction with Physicians, Advance Practice Nursing Staff, nursing staff and HIM Coding Staff to support appropriate reimbursement and capture of clinical severity for the level of service rendered to all patients with a DRG based payer. Collaborates with interdisciplinary teams which include, but are not limited to: physicians, nurse practitioners, physician assistants, coders and department managers for Revenue Integrity, Coding, Case Management, Quality and HIM/Medical Records. Collaborates extensively with other members of the health care team to provide data and solution development processes. Provides ongoing, point of care Clinical Documentation management program education for Physicians, Residents, Medical Students, Advanced Practice Nurses, Nursing Staff and Allied Health Professionals. Monitors changes in rules, regulations and coding guidelines that impact documentation and reimbursement in order to maintain compliance with all applicable agencies.

Requirements:
Nursing degree from an accredited school of nursing
Three years of acute care nursing experience in an acute care hospital, preferably with ICU and/or Medical/Surgical experience
Must be licensed as a Registered Nurse in the state of Georgia