POSITION TITLE: Health Information Management (HIM) Clinical Documentation Specialist
REPORTS TO (TITLE): Director of Health Information Management
DESCRIPTION OF POSITION:
To support the Health Information Management Department through a variety of clerical, technical and related support services. To dictate and edit Discharge Summaries for all physicians in an accurately and timely manner in accordance to hospital policy.
KEY RESPONSIBILITIES :
· Abstract and summarize patient information from the medical record to create hospital discharge summaries .
· Ensures medical record compliance by self - documentation attestation.
· Prepares and sends all documentation to physician for review and approval via facility-specific procedures.
· Complies with hospital policies, including those relating to HIPAA and The Joint Commission.
· This is an on-site position.
Requirements
POSITION Requirements:
Knowledge and Experience:
· High school diploma or equivalent required. Bachelor degree in related healthcare field required.
· Medical school graduate preferred.
· 2 years Health Information/Healthcare experience, experience in psychiatry required.
· Knowledge of medical terminology, with specific familiarity with psychiatric terminology preferred.
· Advanced proficiency in operating medical record software preferred.
· One year of required experience in providing accurate and complete medical record documenation. ..
· Demonstrated knowledge of patient privacy (HIPAA) relative to maintaining medical records required.
Skills and Abilities:
· Maintains confidentiality of patient information at all times.
· Sensitivity to and willingness to interact with persons of various social, cultural, economic and educational backgrounds.
· Proficiency with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel and PowerPoint.)
· Strong organizational skills with ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.
· Strong written and verbal communication skills.
· Strong interpersonal skills. Ability to work with people with a variety of background and educational levels.
· Ability to work independently and as part of a team.
· Good judgment, problem solving and decision-making skills.
· Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.
· Ability to work in a fast-paced, expanding organization.
Physical Requirements :
While performing the duties of this job, this position is frequently required to do the following:
· Use standard office equipment and access, input, and retrieve information from a computer. Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.
· Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.
· Frequent bending, squatting, kneeling, climbing with the use of a step stool and twisting. Lift and carry up to 20 pounds.
· Sit or stand for minimum periods of one hour at a time. Come and go from the work area repeatedly throughout the day.
· Give and follow verbal and written instructions with attention to detail and accuracy.
· Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.
· Vision: see details of objects at close range.
· Coordinate multiple tasks simultaneously.
Benefits
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