Clinical Documentation Specialist - Clinical Information
CHRISTUS Southwestern Louisiana
CHRISTUS St. Patrick Hospital-10100
524 Dr Michael DeBakey Dr
Lake Charles, LA 70601
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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.
- Licensed Registered Nurse, current licensure for the State of Louisiana, BSN preferred. Standard vocational preparation - skilled, 4-10 years. Familiarity with Clinical Documentation Process, coding guidelines, TJC, Federal, and State standards and regulations
- Minimum 5 years experience in the acute care setting, recent experience in the supervision and treatment of adult patients, prior experience in utilization review, discharge planning, quality management or case management preferred. Knowledge of computer software and hardware application and basic knowledge of statistics.
- Skill and proficiency in applying highly technical principles, concepts and techniques that is central to the nursing profession, ability to be objective in stressful situations, advanced communication and interpersonal skills with all levels of internal and external customers. This includes, but is not limited to, medical staff, patients and families, clinical personnel, support and technical staff, outside agencies, and members of the community. Maintain a high degree of confidentiality and adapts easily to ever changing environment