The Clinical Documentation Specialist is responsible for facilitation improvement in the overall quality and completeness of the medical record documentation. Obtains appropriate documentation through extensive interaction with physicians, nursing staff, other patient caregivers and health information management coding staff to ensure that reimbursement if received for the level of services rendered to the patients and that the clinical information utilized in profiling and reporting outcomes is complete and accurate.
RN; BSN preferred
Basic computer skills in word processing and spreadsheet utilization.
Excellent written and verbal communication skills.
Proficient in computer use (desktop and/or laptop).
Demonstrates basic knowledge regarding HIM coding standards.
Analytic skills necessary to accurately assess patient medical records.
Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes.
Ability to walk and stand 80% of work time.
Ability to be flexible and adjust to workload/assignment changes and interruptions.
Healthstream (HLC) modules completed by assigned date.
Complete Associate Self-evaluation and give to Supervisor by assigned date.
Attend 2 of the Associate Round Tables per fiscal year.
Minimum of 5 years recent experience in an acute care setting in a clinical nursing field required.
Prior experience in clinical documentation improvement, utilization review/management, discharge planning, quality management, case management or coding preferred.
Licensed as a Registered Nurse in the State of Louisiana
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.