HCA, Hospital Corporation of America Clinical Documentation Spec in Snellville, Georgia

  • Analyzes inpatient records for status of the patient, current treatment plan and past medical history to identify potential gaps in physician documentation.

    • Based on the review the Clinical Documentation specialists may query the physician verbally and/ or in writing to assure the appropriate documentation is documented in the body of the medical record, to capture the patient’s severity of illness.

    • Able to communicate with attending physicians and residents to validate observations Able to work closely with the HIM coding staff to assure documentation of discharge diagnosis and any co-existing, co-morbidities that are a complete reflection of the patient’s clinical status and care

    • Minimum of 2 years hospital experience required.

    • Recent coding experience,

    • Utilization Review or Case Management Experience preferred

    • Bachelor’s degree in healthcare related field preferred

    • RN or RHIA preferred

Title: Clinical Documentation Spec

Location: Georgia-Snellville-Eastside Medical Center - Snellville

Requisition ID: 08621-9761