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Clinical Documentation Specialist, Saint Louis, Missouri

CategoryHealth Information Management
Job typeFull Time
CountryUnited States
CitySaint Louis
Address1 Barnes Jewish Hospital Plz
Job ID: 1206203
Employment Status: Full-Time
More Information:

Barnes-Jewish Hospital at Washington University Medical Center is the largest hospital in Missouri and is ranked as one of the nation's top hospitals by U.S. News & World Report. Barnes-Jewish Hospital's staff is composed of full-time academic faculty and community physicians of Washington University School of Medicine, supported by a house staff of residents, interns, fellows and other medical professionals. Recognizing its excellence in nursing care, Barnes-Jewish Hospital was the first adult hospital in Missouri to be certified as a Magnet Hospital by the American Nurses Credentialing Center.


Role Purpose

Uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. 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.

  • Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician's clinical documentation.
  • Utilizes hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
  • Initiates physician interaction when abnormal ancillary test findings, ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
  • Partners with other healthcare disciplines and HIMS coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to reconcile the working and final DRG, severity of illness, risk of mortality and quality outcomes.
  • Contributes to provider engagement, relationship establishment and maintenance related to CDI and documentation improvement efforts, with all providers

  • Minimum Requirements

  • Associate's Degree
  • - Nursing/Healthcare related

  • 2-5 years

  • Preferred Requirements and Additional Job Information

  • Bachelor's Degree
  • - Nursing/Healthcare related

    Supervisor Experience
  • No Experience

  • Licenses & Certifications
  • RN
  • Benefits Statement

    Note: not all benefits apply to all openings

    - Comprehensive medical, dental, life insurance, and disability plan options
    - Pension Plan*/403(b) Plan
    - 401(k) plan
    - Tuition Assistance
    - Health Care and Dependent Care Reimbursement Accounts
    - On-Site Fitness Center (depending on location)
    - Paid Time Off Program for vacation, holiday and sick time

    *Pension does not apply to Memorial Hospital, Memorial Hospital East, Alton Memorial or Parkland Health Center

    Legal Statement

    The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job.

    Equal Opportunity Employer
    EmployerBJC HealthCare

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