Summary:
Facilitates improvement in the overall quality, completeness, and accuracy in medical record documentation.
Detailed responsibilities:
• Constructing compliant queries using medical record documentation to reflect severity of illness and risk of mortality of patients.
• Assign appropriate working DRG, diagnoses and procedures.
• Conducts follow-up reviews of clinical documentation.
• Provides one-on-one physician education about documentation needs.
Competencies and skills:
Essential:
• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback. Connects personal work results to the accomplishment of team and organizational goals.
• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence. Views new assignments and job responsibilities as an opportunity for growth.
Education:
Essential:
• Accredited Program
Credentials:
Essential:
• Registered Nurse License
• Registered Health Information Technician
• Registered Health Information Administrator
• Certified Coding Specialist
Education equivalent experience:
Essential:
• Nursing or graduate of an accredited school of HIM
Other information:
Complexity of Work: Requires critical thinking skills, effective communication skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Proficient in basic computer skills
Required Work Experience: RN with 2 years of clinical nursing experience or RHIA/RHIT or CCS with 2 years inpatient coding experience.
••Registered RN or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS)••
Working conditions:
Essential:
• Bending and Stooping 60.00%
• Keyboard Entry 60.00%
• Kneeling 40.00%
• Lifting or Carrying 0 – 25 lbs Non-Patient 40.00%
• Pushing or Pulling 0 – 25 lbs Non-Patient 60.00%
• Pushing or Pulling 26 – 75 lbs Non-Patient 60.00%
• Reaching 40.00%
• Repetitive Movement Foot/Leg 40.00%
• Repetitive Movement Hand/Arm 60.00%
• Sitting 60.00%
• Squatting 40.00%
• Standing 60.00%
• Walking 60.00%
• Audible Speech 60.00%
• Hearing Acuity 60.00%
• Depth Perception 60.00%
• Distinguish Color 60.00%
• Seeing – Far 60.00%
• Seeing – Near 60.00%
• Communicable Diseases and/or Pathogens 40.00%
• Dust 40.00%
• Computer Monitor 60.00%
• Domestic Animals 40.00%
• Wet or Slippery Surfaces 40.00%
Memorial Healthcare System, consisting of 6 acute care hospitals, a nursing home, outpatient facilities, home health services and physician practices, provides quality, comprehensive care to the residents of the surrounding communities. We invite you to join one of the nation’s leading healthcare systems, recognized for use of advanced technology and clinical informatics.
Memorial Support Services provides a variety of business services to support our facilities. The main offices are located in Miramar with satellite offices located throughout our system.
Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.
Scott Smith 