Clinical Documentation Specialist

🔥 0 minutes ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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Tidelands Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Tidelands Health is a comprehensive healthcare provider offering a wide range of medical services and treatment options. With over 200 providers and four hospitals, along with more than 70 outpatient locations, Tidelands Health delivers expert care in specialties such as family medicine, orthopedics, heart care, cancer care, women's care, and more. The organization emphasizes community health, offering resources and support for those impacted by local events, such as the International Paper Mill closure. Tidelands Health also engages the community through educational events, support groups, and health improvement initiatives.

📋 Description

• Evaluate Medical Staff and healthcare team documentation daily under the Clinical Documentation Program • Ensure quality and completeness of clinical documentation for Medicare, Medicaid and other payers for the inpatient population • Analyze patients’ clinical status, treatment plans and medical histories to identify documentation gaps • Collaborate with Coding staff to ensure discharge diagnoses and comorbidities accurately reflect patients’ clinical status and care • Ensure timely, accurate and complete clinical information for measuring and reporting physician and hospital outcomes • Conduct targeted second-level reviews of high- or low-outlier medical/surgical DRGs identified in quarterly PEPPER reports • Assist with education for Medical Staff, Residents, designated Committees and hospital staff on obtaining appropriate medical-record documentation • Contribute actively to departmental SMART goals supporting organizational strategic objectives • Use monitoring tools to track Clinical Documentation Program progress • Participate in implementing new service lines and identify documentation needs for new diagnoses and procedures • Provide physician and staff education related to clinical documentation

🎯 Requirements

• Bachelor's Degree required • Bachelor's Degree in nursing or clinical degree in a related field preferred • Two (2) years’ experience in the clinical field, coding, care management, or equivalent combination of education, training and/or experience demonstrating competence • Strong clinical background • Exceptional problem-solving, time-management and organizational skills • Ability to work independently and communicate effectively and efficiently with Medical Staff and Healthcare Team • Strong familiarity with medical practices, especially disease management and health and wellness programs • Extensive knowledge of medical terminology and regulatory agency requirements • Exceptional written and verbal communication skills • Tact, initiative and confidence to perform the essential functions of the position • One of the following required: Registered Nurse - South Carolina Department of Labor, Licensing and Regulation; Registered Health Information Administrator - American Health Information Management Association; or Certified Coding Specialist - American Health Information Management Association • Light physical demand

🏖️ Benefits

• Day - 8 hour shift • Year-round access to the Myrtle Beach area’s warm, sunny climate and outstanding quality of life • Workplace culture built around inclusion, teamwork, mutual respect and recognition • Equal Opportunity Employer