Job Description

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

• Medical
• Vision
• Dental
• 401(k)
• 3.5 Weeks Paid Time Off
• $25,000 Life insurance policy is provided at no charge to the employee

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