POSITION PURPOSE:

Responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and documents findings. Facilitates modifications to clinical documentation to ensure completeness through extensive interaction with physicians or medical staff departments. Serves as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of documentation. Reports results of audits to departments and committees. Identifies opportunities for intradepartmental and interdepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities.

DUCATIONAL REQUIREMENTS:

Graduate of an approved Health Information Technology/ Management program with credentials of RHIA, RHIA eligible, RHIT, RHIT eligible, CCS, CCS-P and /or graduate from an accredited nursing program with LPN or RN licensure.

EXPERIENCE REQUIRED:

Two years of experience in acute care setting. Knowledge of care delivery documentation systems and related medical record documents. Computer skills and familiarity with basic office equipment required. Exposure to MS DRG coding classification preferred.

PROFESSIONAL LICENSURE AND CERTIFICATION REQUIRED:

RHIA, RHIA eligible, or RHIT, RHIT eligible, or CCS, CCS-P,or RN, LPN licensure