Clinical Documentation Specialist

Company: Atos ( Learn More )

General Information
US-MI-Flint, United States
4 Year Degree
4 to 5 years
Not Specified
Job Description Atos is a global leader in digital transformation with approximately 100,000 employees in 73 countries and annual revenue of around € 13 billion. European number one in Big Data, Cybersecurity, High Performance Computing and Digital Workplace, the Group provides Cloud services, Infrastructure & Data Management, Business & Platform solutions, as well as transactional services through Worldline, the European leader in the payment industry. With its cutting-edge technologies, digital expertise and industry knowledge, Atos supports the digital transformation of its clients across various business sectors: Defense, Financial Services, Health, Manufacturing, Media, Energy & Utilities, Public sector, Retail, Telecommunications and Transportation. The Group is the Worldwide Information Technology Partner for the Olympic & Paralympic Games and operates under the brands Atos, Atos Consulting, Atos Worldgrid, Bull, Canopy, Unify and Worldline. Atos SE (Societas Europaea) is listed on the CAC40 Paris stock index.JOB DESCRIPTION REQUIREMENTS - Must possess a comprehensive knowledge of acute care nursing experience, as normally obtained through a Bachelor of Science, Nursing (BSN) and at least five years of current acute hospital care experience (i.e. medical/surgical unit, intensive care). - Current Registered Nurse License in the State of practice. - Certified Clinical Documentation Specialist (CCDS) preferred. - Certification will be required within 1 year and maintenance of required Continuing Education Units (CEU). - Experience in Utilization Management/Case Management, Critical Care, and patient outcomes/quality management preferred. -Inpatient coding experience desired. - Possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Atos Digital Health Solutions. - Complete a clinical exam and achieve an 80% passing score. - Must be able to travel to various locations (≈20%) as required. The Clinical Documentation Specialist facilitates the accurate representation of the severity of illness/risk of mortality by improving the quality, completeness and accuracy of the physicians' clinical documentation through extensive medical record review and query process. Through active engagement and interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients. Participates in the development and delivery of education for providers and other members of the healthcare team. Comprehends, incorporates, and demonstrates Atos Digital Health Solution's Mission, Vision, and Values in behaviors, practices, and decisions. - Demonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes. Serves as a resource for appropriate clinical documentation. - Conducts concurrent medical record reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital pay for performance diagnosis specific quality outcomes. - Communicates with and educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and pay for performance documentation requirements on an on-going basis. - Collaborates with coding staff to ensure complete documentation of discharge diagnoses/co-morbidities are a complete reflection of the patient's clinical status and care. Resolves all discrepancies in a courteous manner. - Develops and presents on-going documentation education for staff including case managers, coders, physicians, residents, nursing and allied health professionals. - Gathers and interprets clinical documentation data; Identifies documentation concerns, discrepancies, or issues. Determines methods to ensure compliance in accordance with clinical documentation policies and procedures. - Utilizes interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal personnel such as coders, physicians, nursing and allied health professionals, and some external customers including third party payors to resolve issues. - Understands and is able to articulate concepts to physicians and other health care professionals in an effort to educate clinical documentation requirements for both DRG reimbursement and pay for performance quality measures. - Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment. Serves as a role model by demonstrating professional practice behaviors. - Performs other duties as assigned by Leadership. - Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Atos Digital Health Solution's Standards of Conduct, Code of Ethics, as well as, other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior. Physical and Mental Requirements and working conditions: Mental Requirements: - Able to set and organize own work priorities, and adapt to change when needed. -Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles. - Ability to comply with Anthelio Healthcare Solutions' policies and procedures. - Able to spend majority of time utilizing a computer, monitor and keyboard. - Able to perform some lifting and/or pushing/pulling up to 20 pounds. - Able to work with interruptions and perform detailed tasks. - Proficient on working on different projects simultaneously and coordinate work to meet deadlines. - Skilled ability to concentrate and read for long periods of time. - Involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting, and reading. Must be able to sit for long periods of time..
Job Requirements