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Clinical Document Specialist Clinical Effectiveness
Regional Health
Regional Health
 

Job Location: Rapid City, SD
Job Type: Full time
Hours: Scheduled Weekly Hours40
Department: RCH Clinical Effective
Scheduled Weekly Hours:
40
Shift:
Day (United States of America)

Job Summary:

Utilizes clinical expertise to evaluate medical record chart documentation to ensure the clinical documentation reflects the level of service rendered to patients is complete and accurate. Extensive interaction with physicians and multidisciplinary team members required for facilitating modifications to the overall quality and completeness of the medical record documentation through ongoing education and monitoring. Adheres to general hospital and regulatory agency standards and promotes a cooperative work environment by utilizing communication skills, interpersonal relationships and team building.

Job Description:

Essential Functions:
  • Educates all internal customers on clinical documentation opportunities and coding and reimbursement issues.
  • Facilitates appropriateness of clinical documentation through extensive interaction with physicians, nursing staff and coding specialists to ensure that documentation reflects the appropriate level of service rendered to all patients with a DRG based payor.
  • Supports ongoing clinical documentation education for new staff, including new care managers, coders, physicians, residents, allied health professionals and nursing staff.
  • Improves the overall quality and completeness of clinical documentation by performing concurrent and retrospective reviews for specific patient populations to ensure that the resources consumed, risk of mortality, and severity of illness are accurately reflected in the medical record.
  • Inputs case specific information into database for each case reviewed; reviews clinical issues with Coding Specialists to ensure points of clarification have been recorded in the Medical Record.
  • Reviews clinical issues and coding concerns with the coding specialists to support appropriate DRG assignment.
  • Facilitates modifications to the clinical documentation, through the approved query process(es), and provides follow of non-participating providers through the appropriate channels.
  • Maintains positive open communication with physicians, interdisciplinary care team members, coding specialists and department director.
  • All other duties as assigned.

    Additional Requirements:

    Required:
    Education - Bachelors degree in Nursing
    Certification - Registered Nurse (RN) - South Dakota Board of Nursing

    Preferred:
    Experience - 3+ years of Healthcare ExperiencePhysical Requirements:
    Light work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.Make a difference. Every day.Regional Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.

































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        Posted 15 Days Ago








          Full time








            R6269








          About Us














            • Regional Health is an integrated health care system with the purpose of helping patients and communities live well. The organization, with headquarters in Rapid City, S.D., provides community-based health care in more than 20 communities in two states and 32 specialty areas of medicine. As the largest private employer in western South Dakota, Regional Health is comprised of five hospitals, 24 clinic locations and employs nearly 5,000 physicians and caregivers. Regional Health is committed to the future of medicine, with medical training partnerships, a medical residency program, and more than 130 active research studies.








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            Employee Benefits:
            Regional Health offers a highly competitive and comprehensive benefits package that looks out for you and your family. We recognize there are many types of families, with many different needs. That's why our plans are flexible, allowing you to select the individual benefits which fit your personal needs.

            Regional Health is an integrated health care system with the purpose of helping patients and communities live well. The organization, with headquarters in Rapid City, S.D., provides community-based health care in more than 20 communities in two states and 32 specialty areas of medicine. As the largest private employer in western South Dakota, Regional Health is comprised of five hospitals, 24 clinic locations and employs nearly 5,000 physicians and caregivers. Regional Health is committed to the future of medicine, with medical training partnerships, a medical residency program, and more than 130 active research studies.

            How to Apply:





            Regional Health

            Come join us in our pursuit to become the best healthcare system in America!
            Regional Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.

             
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