Centura Health – Garden City, KS

 

Duties/Responsibilities:

Under indirect supervision, facilitates and obtains appropriate physician documentation for any clinical conditions or
procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.
Educates members of the patient care team regarding documentation guidelines and regulatory requirements, including
attending physicians, allied health practitioners, nursing, and case management. Supports timely, accurate, and complete
documentation of clinical information used for measuring and reporting hospital and physician-based outcomes. Works
independently majority of the time.

• Demonstrates excellence in communication skills and interpersonal relations adheres to hospital policies and procedures
and actively promotes the mission and core values of the organization.
• Assumes leadership role to assist in improving the overall quality and completeness of physician clinical documentation
by performing admission and continued stay reviews using clinical documentation and coding guidelines and Milliman criteria.
• Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital
and physician-based outcomes.
• Facilitates and obtains appropriate physicians documentation for any clinical conditions or procedures to support the
appropriate severity of illness, expected risk of mortality, and complexity of care rendered to all patients with DRG-based
payers.
• Demonstrates knowledge of DRG’s, clinical documentation requirements, and referral policies and procedures.
• Able to effectively educate Physicians, coders and others on clinical documentation, coding and reimbursement
opportunities.
• Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied
health practitioners, nursing, and case management.
• Works independently in an effective and responsible manner.

Qualifications:

• Graduate of an accredited School of Nursing.
• BSN Preferred
• Advance knowledge of anatomy and physiology, medical terminology, pharmacology, pathophysiology and disease
process
• Preferred knowledge of DRG assignments, ICD-9 codes, regulatory coding guidelines, and Medicare Part A and Part B
regulatory guidelines
• 3 years nursing experience required and experience n case management, health information management or utilization
review preferred
• Clinical documentation and/or clinical experience preferred with ICU, CCU or strong Med/Surg experience
• Excellent organization, analytical, writing and interpersonal skills
• Dependable and self-directed with excellent critical thinking, problem-solving and deductive reasoning skills
• Excellent communication, computer, critical thinking, organization skills and multi-disciplinary tasks.
• Exhibits knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and/or procedures
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG
assignments
• Advance knowledge of Microsoft Office applications and troubleshooting computer problems

Contact Information:

Name: Mandy Gray

Email: MandyGray@Centura.org

Web Site: https://careers.centura.org/job/Colorado-Springs-Clinical-Documentation-Specialist-CO-67846/402675500/?locale=en_US