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Job Objective :

Under the direction of the Chief Medical Officer or designee, the Clinical Documentation Specialist is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records to evaluate and ensure the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided. The CDS will work closely with the medical staff to facilitate appropriate clinical documentation of patient care.

Duties and Responsibilities:

Non-Essential Duties:

· Assist coworkers, medical staff, patients and public as needed.

Knowledge, Skills and Abilities:

Knowledge

· 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.

· Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.

· Working knowledge of inpatient admission 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.

· Working knowledge of Medicare reimbursement system and coding structures preferred.

Skills

· Skilled in dealing with adversity and resistance in an effective and professional manner while staying focused and determined and continuing to build and maintain a positive rapport.

· Well-developed organizational, analytical writing and interpersonal skills.

· Critical thinking, problem solving and deductive skills.

· Computer skills, including familiarity with Microsoft products such as MS Word, Excel and Powerpoint.

· Skilled in managing a heavy caseload in an organized and efficient manner.

Abilities

· Ability to be dependable and self-directed.

· Ability to communicate, interact and develop a rapport with Physicians.

· Ability to work independently with minimal supervision.

· Ability to learn and develop the skills necessary to perform with significant autonomy.

· Ability to present/facilitate training activities for individuals and groups.

· Ability to learn advanced aspects of Coding and reimbursement systems.

· Ability to review and enter data into various computer applications.

· Ability to review records and verify patient information.

AVH Values: All AVH employees will effectively demonstrate these values:

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
• Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
• Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.
  

Education and Experience:

Education

· RN or Medical Graduate Degree (M.D.) or equivalent.

Experience

· Minimum of 2-3 years’ clinical experience in an acute care setting.

Required Licensure and/or Certifications:

· Certified Coding Specialist (CCS) or Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) or obtained within 12 months from hire date.

AVH Conduct/Compliance Expectations :

· Ability to adhere with AVH Leaves of Absence Policy

· Ability to adhere with AVH Paid Time Off (PTO) Policy

· Ability to adhere with AVH Recording of Hours Worked Policy

· Ability to adhere to the department dress code

· Ability to organize work and establish priorities

· Ability to expand on own initiative in performance of duties

· Skill and ability to follow the telephone etiquette/standards

· Conforms to AVH Standards of Excellence

· Ability to function effectively under pressure and meet time parameters

· Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff

· Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVH

· Ability to maintain the confidentiality of patient, hospital and department information

· Ability to adhere to safety rules and regulations

· Safely and effectively uses all equipment necessary to carry out duties

· Ability to interpret and function under hospital and department policies and procedures

· Conforms with required and appropriate Joint Commission requirements

· Conforms with and supports hospital quality assurance and improvement guidelines

· Ability to participate effectively in department and hospital staff education

· Display a willingness to work as a team player

· Ability to give and support the highest level of patient/customer satisfaction at all times

· Supports and adheres to the values and mission statement established by the AVH Board of Directors

· Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.

· Ability to follow the Code of Conduct

Physical Requirements and Working Conditions:

· Ability to follow the Code of Business Conduct (Standards of Business Ethics and Integrity).

· Must be capable of attending meetings and conducting visit across the hospital campus.

· Must be capable of working a flexible schedule depending upon department and/or physician needs.

· Work is usually performed in a normal office environment and may require long period in sedentary position performing one function.

· Frequent use of keyboard and video display terminal.

· Must be able to tolerate repetitive arm and hand movements.

A detailed description of the physical requirements of this job is maintained in the Employee Health Department .

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Education and Experience:

Education

· RN or Medical Graduate Degree (M.D.) or equivalent.

Experience

· Minimum of 2-3 years’ clinical experience in an acute care setting.

Required Licensure and/or Certifications:

· Certified Coding Specialist (CCS) or Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) or obtained within 12 months from hire date.

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