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Maria Parham Health
Who We Are:
People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. With 205 licensed beds, Maria Parham Health is equipped for every health care need one can encounter. We are fully licensed by Joint Commission, the College of American Pathologists, and Rated Highest in Patient Safety from Leapfrog.
Where We Are:
Henderson offers a great outdoors, including the region's largest lake, providing endless hours of fun boating, fishing, skiing and camping. Throw in great golfing, hunting and two fantastic recreational organizations and you may find yourself having a hard time deciding what to do next!
Why Choose Us:
* Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
* Competitive Paid Time Off, PTO cash out, and PTO donation programs
* Employee Assistance Program - mental, physical, and financial wellness assistance
* Loan Repayment and Tuition Reimbursement/Assistance for qualified applicants
* Robust employee recognition and awards programs
* And much more...
Position Summary:
Responsible for the facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.
Reports to: Int Qual/Risk/Pat Safety Director
Essential Functions of the Position
- Performs initial assessment and data collection upon entry into the MPMC system per policy. Reviews all Medicare observation and new admission patients for chief complaint, history and physical, ED notes if applicable, and admission diagnostic test results.
- Identifies potential length of stay for new admissions.
- Performs re-assessment on a regular basis as indicated. conducts continued stay reviews.
- Participates in the formulation of an individualized goal directed plan of care and participates in the prioritization of care based on all available assessment data.
- Ensures that causative organisms are listed in progress notes or discharge summary for all positive cultures.
- Provides educational programs for the medical, hospital and PRM staff regarding UM and continuum of care issues.
High School Diploma or Equivalent required
Bachelor's degree Preferred
Certification: BLS Basic Life Support required
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.