HCA, Hospital Corporation of America Clinical Documentation Spec in Snellville, Georgia
Eastside is a 310-bed, full-service, acute care medical center with nearly 1,200 employees and 450 affiliated physicians. The hospital is fully accredited by The Joint Commission. Eastside Medical Center has been a leader for 31 years in a wide range of state of the art healthcare, including emergency services, neurosurgery, orthopaedics, women’s services, neurosciences, oncology, cardiology and behavioral health.
- 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
Special Skills Required:
* Must possess advanced communication and interpersonal skills with all levels of internal and external customers.
* Must demonstrate excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills.
* Must be proficient in organization and planning.
* Must possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching.
* Must demonstrate working knowledge of quality improvement theory and practice.
* Must have working knowledge of DRGs and medical necessity criteria. * Knowledgeable of Federal, State, and other payers’ regulations, requirements, and criteria.
Degree of Supervision Required:Minimal, must be able to work independently
Title: Clinical Documentation Spec
Location: Georgia-Snellville-Eastside Medical Center - Snellville
Requisition ID: 08621-9761