Physical Therapy at St. Luke's · 1 day ago
Clinical Documentation Specialist
Bethlehem, PA
Full-time
Onsite
Senior Level
5+ years expSt. Luke's is dedicated to providing excellent care to the sick and injured, and they are seeking a Clinical Documentation Specialist. This role involves reviewing inpatient medical records to ensure accurate representation of illness severity, collaborating with healthcare professionals, and educating clinical staff on documentation improvement.
Health CareHospitalRehabilitation
Responsibilities
Following orientation period, meets established productivity targets for new and follow-up inpatient record reviews per day. If unable to perform reviews, seeks assistance from peers or supervisor
Formulates credible clinical documentation clarifications in 360’ format to improve clinical documentation of principal diagnosis, co-morbid conditions, present on admission status, and quality initiatives that support patient’s severity of illness, risk of mortality and patient safety indicators
Maintains an accuracy rate of 94% or greater in identifying correct concurrent initial and possible DRG when 2 or more diagnoses meet definition of PDX; reconciles correctly after coding to reflect highest severity and relative weight; ensures documented conditions, clarifications, and coded diagnoses are clinically valid and compliant; conducts follow up reviews utilizing department approved case prioritization methods; and utilizes process flow map in both concurrent and post discharge processes
Utilizes effective and appropriate verbal and written communication with physicians and other providers of record to validate observations and clarify additional and/or more specific documentation to accurately reflect the patient’s condition. Manages electronic communication efficiently and effectively
Demonstrates knowledge of International Classification of Diseases coding regulations, applies to ongoing evaluation of medical record documentation, and works closely with Coding staff to assure documented diagnosis (es) and co-morbidities gives a complete and compliant reflection of the patient's clinical status and care
Accurately inputs and analyzes data with the Clinical Documentation and performs re-reviews on a timely basis to identify changes in a patient’s condition through follow up or by writing new clarifications
Demonstrates competency in computer and network applications as necessary to perform role
Completes educational strategies to keep skills/knowledge current in documentation process and assists and supports with ongoing education for both formal and informal education of physician, nursing, and other clinical staff
Works collaboratively with healthcare team to facilitate documentation. Maintains good rapport and cooperative relationships. Approaches conflicts in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution
Qualification
Required
Registered Nurse required
Current license required
Minimum five years of RN/licensed provider experience in adult inpatient medical-surgical or critical care with thorough understanding of disease processes
Demonstrates knowledge of International Classification of Diseases coding regulations
Accurately inputs and analyzes data with the Clinical Documentation
Demonstrates competency in computer and network applications as necessary to perform role
Completes educational strategies to keep skills/knowledge current in documentation process
Works collaboratively with healthcare team to facilitate documentation
Sitting for up to 7 hours per day, 3-4 hours at a time; standing for up to 7 hours per day, 4 hours at a time; walking for up to 2 hours a day, 1 hour at a time
Requires crouching, kneeling, and lifting of objects weighing up to 40 pounds
Requires hand and finger dexterity to use computer equipment
Proficiency in keyboarding and use of computer mouse
Ability to perform focused record reviews in a setting that may include noise or other distractions
Seeing as it relates to general, near, color and peripheral vision
Hearing as it relates to normal and telephone conversations
Ability to walk and stand 80% of work time
Preferred
BSN preferred
Prior clinical documentation specialist experience and credential preferred
Background knowledge of HIM field helpful, with focus on MS-DRG reimbursement, AHA coding guidelines, and compliance
Company
Physical Therapy at St. Luke's
Physical Therapy at St. Luke's is a patient-oriented rehabilitation practice that emphasizes education, healing, and exceeds expectations.
201-500 employees
Funding
Current Stage
Growth StageCompany data provided by crunchbase