What are the responsibilities and job description for the Clinical Documentation Specialist - Health Information Management (Full Time) - 7184 position at CABELL HUNTINGTON HOSPITAL\/ST. MARY?
St. Mary's Medical Center is seeking a Clinical Documentation Specialist. The Clinical Documentation Specialist, under the supervision of the Director of Health Information Management or authorized designee the Clinical Documentation Specialist's primary responsibilities are to ensure that accurate and appropriate physician documentation exists in the patient medical record to support assignment of the most appropriate DRG by the coding staff and to facilitate the accurate representation of the severity of illness and risk of mortality.. The Clinical Documentation Specialist is responsible for extensive medical record review, interaction with physicians, nurse practitioners, physician assistants, and HIM professionals. The Clinical Documentation Specialist will query physicians and other clinicians to facilitate obtaining additional documentation as necessary in the medical record to best describe the most accurate picture of the patient’s condition. The Clinical Documentation Specialist completes chart review for medical necessity and to communicate educational information to the physician regarding clinical documentation improvement matters and the need for accurate and complete documentation in the patient record.
