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