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Nursing

Clinical Documentation Spec

  • Springfield, MO
  • Posted: February 19, 2024
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Summary

Best in Class Work Environment

    • 5x Modern Healthcare Best Places to work
    • America’s Greatest Workplaces 2023 – Newsweek
    • Best Employers for New Grads 2023- Forbes
    • Greatest Workplace for Women 2023 - Newsweek

Benefits

    • Robust, fully customizable benefits package including Medical/Vision/Dental and more!
      • No cost eCare visits
      • Employer-provided mental health services for employees and eligible family members
    • Retirement with employer match up to 5%
    • Tuition discounts and reimbursement available for continuing your education
    • CoxHealth Fitness Center and Child Care discounts
 
Job Summary
  • This position is responsible for facilitating timely and accurate physician documentation in the medical record through concurrent chart review. Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders is key to the success of this position. This position is also responsible for ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines. Understand and utilization of ICD-10-CM and PCS coding assignment and follow Official Coding Guidelines.  
Job Requirements
  • Education
    • Required: Graduate of an approved nursing program
    • Preferred: Bachelor's Degree in Nursing
  • Experience
    • Required: 3 year’s acute care experience, 5 years preferred
    • Preferred: Preferred experience in (ED, ICU, Neuro or Stepdown)
  • Skills
    • Ability to apply coding guidelines when reviewing documentation in the medical record.
    • Ability to perform computer data entry.
    • Ability to work with others and communicate effectively.
  • Licensure/Certification/Registration
    • Required: Registered Nursing License
    • Preferred: CCDS or CDIP
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Job Information

Corporate
HIM Documentation Improvement
Part Time - Day Shift - 8:00 AM - 4:30 PM
Nursing
Req #: 202403697-78335
Remote Work Type: Hybrid/Rotational

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