Registered Nurse Tier 1(Union)
Appalachian Regional Healthcare
Outpatient Clinical Documentation Specialist
- Requisition ID
- 2024-32140
- # of Openings
- 1
- Category
- Business Professional
- Community
- System-Hazard
- Posted Date
- 3 days ago(10/22/2024 1:44 PM)
- Position Type
- Regular Full-Time
- Department
- Coding
- Shift
- Day Shift
Overview
The Outpatient Clinical Documentation Specialist is responsible for following the outpatient facility processes and
providing clinically based reviews of documentation to capture accurate charges for services rendered.
Special Instructions
Responsibilities
The goal of concurrent review includes facilitation of appropriate physician documentation of care
delivered to accurately reflect patient severity of illness, risk of morality and care provided. Specific
reviews are both determined internally and by requirements/requests of external payers or regulatory
agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and
compliant reimbursement for acute care services.
Duties include:
Conduct chart reviews of Clinical departments daily to regularly review the documentation and chargeaccuracy and to integrate into educational sessions with the Clinical departments and medical staff
Performs review of accounts identified as potentially missing charges and conducts additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges
Provides reporting and feedback to the Clinical Departments based on claim accuracy and chart reviews to encourage greater understanding and ownership of documentation and charge accuracy
Maintains current knowledge of applicable regulatory standards, which may impact utilization of processes and systems
Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization
Provides education to providers and other staff as deemed appropriate
Maintains the ability to be flexible and prioritizes daily responsibilities
Attends meetings, educations sessions and trainings as scheduled
Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines All other duties as assigned
Qualifications
Education
Bachelor’s, or Associate’s Degree in Nursing or Health Information Management or related field
Minimum Work Experience
Minimum of 5 years of clinical experience in an acute care setting or of 5 years experience in coding in an acute hospital setting
Required Licenses/Certifications
RN, BSN, RHIA or RHIT credential required
Required Skills, Knowledge, and Abilities
· Knowledge of care delivery documentation systems and related medical record documents.
· Knowledge of age-specific needs and the elements of disease processes and related procedures.
· Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
· Excellent written and verbal communication skills.
· Excellent critical thinking skills.
· Demonstrated good nurse-physician relationships in the past and has the ability to maintain those going forward.
· Working knowledge of outpatient criteria.
· Ability to work independently in a time-oriented environment.
·Computer literacy and familiarity with the operation of basic office equipment.
· Assertive personality traits to facilitate ongoing physician communication.
· Ability to stand and walk for periods of time is required in the performance of job responsibilities.
· Working knowledge of Medicare reimbursement system and coding structures preferred, but not required.
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