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Clinical Documentation Specialist

Job ID R464 Full / Part Time:Full time
Location:Holyoke,Massachusetts
Regular/Temporary:Regular

Summary: 

The Clinical Documentation Specialist acts as a liaison between medical staff, Nursing, Coding and QI specialist to ensure the clinical documentation supports and reflects the most appropriate level of services and resources provided.

Baystate Health is seeking a full time Clinical Documentation Specialist. The Clinical Documentation Specialist acts as a liaison between medical staff, Nursing, Coding and QI specialist to ensure the clinical documentation supports and reflects the most appropriate level of services and resources provided.

Responsibilities:

  • Provides clinically based concurrent review of inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnoses and procedures
  • Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support correct coding, reimbursement and quality initiatives.
  • Proactively contacts physicians or other departments regarding procedures/diagnoses to ensure proper documentation. This includes joining physicians and other clinical staff in educational sessions and “rounds” on the nursing units.  Participates, when appropriate, with questions to improve overall documentation of the care being rendered to the patient.
  • Identifies opportunities to improve  documentation and coding workflow process. Collaborates with the HIM management and staff.
  • Prepares and presents educational sessions to physicians on proper documentation. 
  • Monitors and participates in performance improvement initiatives.
  • Participates in the planning for assigned inter/intra departmental meetings and presentations

Required Work Experience: 

 5 years in an acute care setting; If Physician trained experience, RN will not be required

Preferred Work Experience: 

Certifications:  RHIA, RHIT, CDS, CCS is preferred.

  • Anatomy and Physiology Medical Terminology is required.
  • 5 years of Clinical Documentation Specialist is preferred.
  • CCS/CDS/ICD 10  is preferred.
  • Familiarity with Cerner and 3M applications.

Skills and Competencies: 

  • extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting

Education:

Diploma in Nursing: Nursing (Required)

Languages:

Certifications:

Certified Clinical Documentation Special - Various, Certified Coding Specialist - American Health Information Management Association, Registered Health Information Associate - American Health Information Management Association, Registered Health Information Technician - American Health Information Management Association, Registered Nurse - State of Massachusetts

Work Experience:

Competencies:

Responsibilities:

Skills:

Training Details:

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

For a complete listing of all Baystate Health jobs, or to access an incomplete application, click here

If you are a job seeker with a disability, or are assisting someone with a disability, and require accessibility assistance or an accommodation to apply for one of our jobs, please submit a request by telephone or contact us through the email link below. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. Please include your contact information and specific details about your requested accommodation to support you during the job application process.

To request assistance by phone, contact us at: 413-794-3666

For Email requests: talent.acquisitionFD@baystatehealth.org

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