HCA, Hospital Corporation of America Clinical Documentation Specialist PRN in Wichita, Kansas

The Clinical Documentation Specialist facilitates improvement of clinical documentation through concurrent interaction with physicians and other members of the healthcare team to support appropriate clinical severity capture and reporting.

  • Performs concurrent review of the clinical documentation in the medical record to clarify ambiguous, incomplete or conflicting documentation as it relates to diagnoses, conditions and/or procedures

  • Queries the medical staff and other care givers as necessary via written/verbal inquiry utilizing corporate approved and required forms to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality

  • Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately on the DRG worksheet

  • Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes

  • Maintains compliance with corporate policies regarding documentation improvement

  • Maintains the ability to be flexible and prioritizes daily responsibilities

  • Works collaboratively with HIM coding staff to resolve DRG discrepancies

  • Assists the Quality Department staff by notifying the department of potential core measure issues/concerns

Required Registration, Licensure or Certification

  • CCS

Preferred Education or Experience

  • Registered Nurse (RN) or RHIA/RHIT with CCD

  • Bachelor's of Science in Nursing or Registered Nurse with 10 years acute care experience or RHIA/RHIT with 10 years inpatient coding experience

  • Graduate of an associate's degree in nursing program or health information technology program

Required Knowledge and Skills

  • Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting

  • Knowledge of care delivery documentation systems and related medical record documentation

  • Strong broad-based clinical knowledge and understanding of pathology/physiology

  • Excellent written and verbal communication skills and critical thinking skills

  • Knowledge of age-specific needs and the elements of disease processes and related procedures

  • Ability to work independently in a time oriented environment

  • Assertive personally traits to facilitate ongoing physician communication

  • Computer literacy and familiarity with the operation of basic office equipment

  • Working knowledge of inpatient admission criteria

  • Working knowledge of inpatient admission criteria

Preferred Knowledge and Skills

  • Working knowledge of core measures

  • Working knowledge of Medicare/reimbursement system and coding structures preferred

Title: Clinical Documentation Specialist PRN

Location: Kansas-Wichita-Wesley Medical Center

Requisition ID: 00323-16108