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Clinical Documentation Specialist

Kelly Services

Orlando, FL
Job Code:
Kelly Services
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Job Details

Job Title Clinical Documentation Specialist

Jobid US589JRB_BH1427287

Location: Orlando, FL, 32806, USA

Description This position reviews inpatient medical records throughout hospitalization, analysis of clinical status of patient in reference to ICD10 coding and ascertains potential gaps in clinical documentation; attends clinical rounds and communication with attending physicians, consultants and residents to validate specific documentation and co-morbidities, which reflect the true representation of the patient’s clinical status and care.

**Essential Functions:**

1. Reviews inpatient records throughout the hospitalization – assessing orders, patient class, current treatment plan and documentation recorded for “gaps” in vermicular when compared to treatment plans and the documentation in the record.

2. Demonstrates and applies knowledge of AHA’s Inpatient Coding rules (i.e. Coding Clinic) and serves as expert in clinical documentation knowledge to Coder II (inpatient coder) with collaborative process on querying clinical staff.

3. Identifies patients appropriate for the Hospital Quality Measures, and prompts physician, RN, and ancillary clinical support for clinical documentation according to the accepted standards

4. Identifies trends and/or opportunities to improve clinical documentation; presenting opportunities in addition, potential solutions to the HIM management team.

5. Uses expert knowledge of software tools to appropriately query physicians for documentation

6. Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes

7. Reports trends or gaps in missed charge capture to Senior Manager, Hospital Coding and Billing.

**Job Requirements**

+ Bachelor's Degree required. Preferred Undergraduate Course of Study: (RN) Nursing.
+ Minimum of five (5) years' experience required.
+ RN, RHIA, or CCS required.
+ AHIMA credential CDIP preferred.
+ Ability to provide independent and critical thinking regarding data analysis.
+ Ability to execute quantitative analysis using Crystal Reporting and Excel.
**Why Kelly** **®** **?**

At KellyServices ® , we work with the best. Our clients include 95 of the Fortune100 ™ companies, and more than 70,000 hiring managers rely on Kelly annually to accessthe best talent to drive their business forward. If you only make one career connection today, connectwith Kelly.

**AboutKelly Services** **®**

As a workforce advocate for over 70 years, we are proud to directly employ nearly 500,000 peoplearound the world and have a role in connecting thousands more with work through our global network oftalent suppliers and partners. Revenue in 2017 was $5.4 billion. Visit and connect with us on Facebook, LinkedIn and Twitter .

Kelly Services is an equal opportunity employer including, but not limited to, Minorities, Females,Individuals with Disabilities, Protected Veterans, Sexual Orientation, Gender Identity and iscommitted to employing a diverse workforce. Equal Employment Opportunityis The Law.

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