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Clinical Doc Specialist RN: Spring Branch Medical Center

Position Responsibilities:

Concurrent analysis of in patient records to establish applicable diagnosis
Intervene with Clinical and Medical Staff to ensure documentation supporting applicable diagnosis
Educate Clinical and Medical Staff regarding documentation requirements specific to disease/diagnosis

Department Specific Criteria:

Concurrently reviews selected admissions to identify most appropriate principal and secondary diagnosis to accurately reflect the patients severity of illness
Communicates with physicians and clinicians regarding missing, unclear or conflicting medical record documentation to clarify and obtain needed documentation.
Develops clinician or physician education strategies to promote complete and accurate documentation and correct negative trends
Confers with Coders concurrently to ensure appropriate DRG and completeness of supporting documentation
Develops tools and coordinates audits for compliance
Gathers and analyzes information pertinent to documentation findings and outcomes
Identifies patterns and trends variance, identifying opportunities for improvement
Researches literature to identify new methods in development for disease components and documentation

Qualifications:

Current RN Tennessee License
Bachelors Degree in Nursing or Healthcare related field preferred
Experience in Quality, Case Mgm, Clinical Audit or Data Abstraction necessary
Interpersonal Communication skills to motivate and manage an improvement process