Clinical Documentation Spec - Clinical Documentation - Hybrid - Days - FTE

Grady Health System offers many career paths. Whether you have many years of experience or are in the early stages on your career, you can find a rewarding position at Grady!

SUMMARY
Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and Health Information Management coding staff . Support appropriate reimbursement and clinical severity is captured for the level of service rendered to all patients with a DRG based payer. Collaborates with interdisciplinary teams including, but not limited to, physicians, nurse practitioners, PA's and the department managers for Revenue Integrity, Coding, Case Management and Health Information Management. Collaborate extensively with other members of the health care team to provide data and solution development processes.

Provides ongoing, point of care Clinical Documentation management program education for nurses, physicians, and allied health professionals. Tracks and trends program compliance. Assumes responsibility for professional development by participating in workshop, conferences, and/or in-services and maintains apropriate records of participation.

QUALIFICATIONS

• RN / BSN Degree preferred
• Licensed as a Registered Nurse in the state of GA or Registered Health Information Administrator (RHIA).
• Five (5) years recent clinical experience in a hospital setting, or four (4) years recent clinical experience and two (2) years ICD-9 Coding experience (optional).
• Utilization Review, Care Management or coding experience preferred.
• Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication.
• Professional, team player, able to communicate well with others. Strong interpersonal skills, pleasing personality, positive. Regular significant contacts with other personnel throughout and outside the Hospital. Contacts may be in person, by telephone, or through correspondence.
• Flexible with a working knowledge of all areas of adult medicine.
• Sitting, standing, and light lifting.
• Good critical thinking skills, able to assess, evaluate, and teach.
• Flexible with strong knowledge of all areas of adult medicine.
• Uses sight and sensory.
• Serve the population of physicians, patients, family members, and employee.