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Clinical Documentation Spec

Eastside Medical Center - Snellville - Snellville, Georgia

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Job Code: 08621-9761

Full-time

No Weekends

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.


Position Responsibilities:

  • 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. 
 

Qualifications:

  • 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
 
Employees Supervised: NA

Last Edited: 04/19/2017

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