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Macon, GA, United States
Job ID: 61936
Job Family: Patient Accounting/Registration
Status: Full Time
Job Type: Regular
Department Name: 12011053141601-Patient Access
The Clinical Documentation Specialist conducts concurrent reviews of the medical record and often serves as a liaison to the medical staff to ensure that the medical record is complete and accurate and provides a clear picture of the patient’s clinical record and treatment. Therefore, the CDS is often tasked with obtaining appropriate clinical documentation to ensure that the level of service rendered to the patient and the clinical complexity of the patient’s condition are completely and accurately documented. The CDS helps to identify potential gaps in clinical documentation and ensures that the severity of the patient’s illness, the intensity of services, and the risk of mortality are appropriately reflected in the record. Works with coding staff to support appropriate DRG Validation and reimbursement to the hospital.
What we offer:
Evidence-based nursing practice
Comprehensive Benefits (Medical, Dental, Vision, Health Savings and Spending Account options)
403b Retirement Savings Plan with employer-matching contributions
Paid Time Off (PTO) and Extended Illness Benefit (EIB)
Education Assistance Plans
Employee Fitness and Wellness Center
What you will need:
Associate's or Bachelor's degree in nursing.
Current valid Georgia nursing license or eNLC nursing license.
Three (3) to Five (5) years clinical experience in an acute care hospital, preferably with ICU and/or Medical/Surgical experience.
Certified Clinical Documentation Specialist (CCDS) and/or Certified Coding Specialist (CCS) preferred.
Working knowledge and experience in ICD10 Diagnosis and Procedure Coding. Common Procedural Terminology (CPT) coding knowledge preferred.