Clinical Documentation Specialist - Georgetown Memorial Hospital (Georgetown, SC)
- Tidelands Health
- Myrtle Beach, SC, USA
Job Description
Clinical Documentation Specialist - Georgetown Memorial Hospital (Georgetown, SC)
Responsibilities
Position Summary:
Responsible for day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the Clinical Documentation Program. Ensures overall quality and completeness of clinical documentation for Medicare, Medicaid or other payers for inpatient population. Supports goal of ensuring that clinical severity is captured for the level of service rendered to all patients. Capability to analyze clinical status of patient, current treatment plan, and past medical history to identify potential gaps in Provider documentation. Able to work closely with Coding staff to assure documentation of discharge diagnoses and co-existing comorbidities are a complete and accurate reflection of the patient’s clinical status and care. Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
Qualifications
Experience:
Two (2) years experience in Clinical field, Coding, Care Management or any combination of education, training and/or experience which demonstrates competence as described in Special Skills and Position Summary; Registered Nurse or Clinical Degree in related field preferred.
Education:
Bachelors Degree preferred
Licensure/Certification:
Must have one of the following – RN, RHIA, CCS
Other:
Special Skills: Strong Clinical background. Exceptional problem-solving, time management and organizational skills. Ability to work independently and communicate effectively and efficiently with Medical Staff and Healthcare Team. Strong familiarity with medical practices, especially disease management and health and wellness programs. Works with the Medical Staff and Documentation Team members to provide physician and staff education related to clinical documentation. Have extensive knowledge of medical terminology and regulatory agency requirements. Possess exceptional written and verbal communication skills in order to establish and maintain successful working relationships with all levels of staff. Possess tact, initiative and confidence to meet the essential functions of the position.
Physical Requirements: Light
While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert up to 15 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or up to 5 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
As our region’s largest health care provider, Tidelands Health is dedicated to keeping the communities we serve healthy and active, inside and outside of the hospital. Ours is a singular commitment: Better health begins here.
Tidelands Health is three hospitals and more than 40 outpatient locations that stretch from North Myrtle Beach to Hemingway. More than 200 physicians and 1,800 employee partners are working side by side with our patients to transform the health of our region -- promoting wellness, preventing illness, encouraging recovery and restoring health.
Tidelands Waccamaw Community Hospital
In 2002, Tidelands Waccamaw Community Hospital opened in Murrells Inlet to accommodate the needs of the population in the fastest-growing northern reaches of our system’s service area. Rated one of America’s 100 Best Hospitals for Orthopedic Surgery by Healthgrades in 2015, Tidelands Waccamaw holds Joint Commission certifications in childbirth and joint replacement and is an advanced primary stroke center. Tidelands Waccamaw is a Pathway to Excellence designated hospital signifying the facility as a best-in-class work environment for nursing professionals.
Tidelands Georgetown Memorial Hospital
Tidelands Georgetown Memorial Hospital is where the Tidelands Health organization began more than 60 years ago. Steady, intentional, forward-thinking reinvestment in the facility has built a leading center of wide-ranging medical care in our community. Tidelands Georgetown is an advanced primary stroke center, an accredited chest pain center and a designated baby-friendly hospital. The facility is also a Pathway to Excellence designated hospital.
Tidelands Waccamaw Rehabilitation Hospital
Tidelands Waccamaw Rehabilitation Hospital is a hospital within a hospital, located inside Tidelands Waccamaw Community Hospital. It is the region’s only inpatient rehabilitation facility, providing concentrated physical, occupational and speech therapy for acute patients. The rehabilitation hospital is one of a select few facilities in South Carolina accredited by the Commission on Accreditation of Rehabilitation Facilities.
Two cancer treatment centers
Tidelands Health was the first to bring radiation therapy to Georgetown County when we opened the Francis B. Ford Cancer Treatment Center in 2004. And the system’s cancer treatment options have expanded at Tidelands Waccamaw Cancer Center in Murrells Inlet. Striving to deliver even greater quality cancer care, Tidelands Health is a member of the MUSC Hollings Cancer Center’s Research Network, providing access to clinical trials research across the state.
Tidelands NextStep Services
Tidelands NextStep Services is a network of more than a dozen rehabilitation, pain management and wound care facilities easing the pain and restoring the mobility of Tidelands residents. The highly trained therapists and specialists at NextStep provide the therapies, care and compassion so vital to complete rehabilitation and healing.
Primary and specialty care
Tidelands Health Group is our growing network of primary and specialty care physicians specializing in areas such as family medicine, dermatology, gastroenterology, oncology, orthopedics, women’s health and general surgery. These physician practices continue to grow to meet the evolving needs of patients in Georgetown, Horry and Williamsburg counties.