Clinical Documentation Specialist
Welcome to Tenet Healthcare, where we prioritize delivering quality care to our patients through efficient and accurate clinical documentation. As a Clinical Documentation Specialist, you will play a crucial role in ensuring that our medical records are complete, compliant, and reflective of the care provided. We are seeking individuals who are detail-oriented, knowledgeable in medical terminology and coding, and possess strong communication skills to join our team. If you are passionate about making a difference in healthcare and have the necessary qualifications, we encourage you to apply.
- Review and analyze medical records for completeness and accuracy, ensuring all necessary information is documented.
- Collaborate with healthcare providers and other team members to clarify and obtain missing or unclear documentation.
- Conduct thorough audits of medical records for compliance with regulatory and coding guidelines.
- Utilize knowledge of medical terminology and coding to accurately assign appropriate codes to diagnoses and procedures.
- Educate healthcare providers and other staff on proper documentation practices and coding guidelines.
- Identify and communicate opportunities for improvement in clinical documentation and coding processes.
- Stay updated on changes in coding and documentation regulations and guidelines to ensure compliance.
- Utilize electronic health record systems and other software to review and analyze medical records.
- Communicate with insurance companies and other third-party payers to resolve documentation and coding issues.
- Participate in interdisciplinary team meetings to provide input on documentation and coding related matters.
- Maintain confidentiality and adhere to HIPAA regulations while handling sensitive medical information.
- Complete all documentation and reporting accurately and in a timely manner.
- Act as a resource for other team members regarding clinical documentation and coding questions and concerns.
- Continuously seek opportunities for professional development and stay updated on industry changes and advancements.
- Contribute to a positive and collaborative work environment that values open communication and teamwork.
Bachelor's Degree In Healthcare-Related Field: A Strong Foundation In Healthcare And Medical Terminology Is Essential For A Clinical Documentation Specialist. A Bachelor's Degree In A Relevant Field Such As Health Information Management Or Nursing Provides The Necessary Knowledge And Skills For This Role.
Certified Clinical Documentation Specialist (Ccds) Certification: This Certification Demonstrates A High Level Of Expertise In Clinical Documentation Improvement And Is Preferred By Many Employers, Including Tenet Healthcare. It Shows A Commitment To Staying Current With Industry Best Practices And Guidelines.
Minimum Of 2-3 Years Of Experience In Clinical Documentation Improvement: Previous Experience In A Similar Role Is Highly Valued By Tenet Healthcare. This Experience Should Include Working With Electronic Health Records, Coding Guidelines, And Clinical Documentation Improvement Processes.
Strong Understanding Of Coding Guidelines And Regulations: Clinical Documentation Specialists At Tenet Healthcare Must Have A Thorough Understanding Of Coding Guidelines, Such As Icd-10 And Cpt, As Well As Regulatory Requirements, Such As Cms Documentation And Reimbursement Policies.
Excellent Analytical And Communication Skills: The Ability To Analyze Complex Medical Records And Communicate Findings Clearly And Effectively Is Crucial For A Clinical Documentation Specialist. This Role Involves Collaborating With Various Healthcare Professionals, So Strong Interpersonal Skills Are Also Important.
Data Entry
Time Management
Attention to detail
Analytical Thinking
Medical Terminology
Computer proficiency
Interpersonal Communication
Documentation Accuracy
Clinical Knowledge
Coding Knowledge
Coding Guidelines
Communication
Conflict Resolution
Emotional Intelligence
Leadership
Time management
creativity
Critical thinking
Teamwork
Adaptability
Problem-Solving
According to JobzMall, the average salary range for a Clinical Documentation Specialist in Delray Beach, FL, USA is $56,000 to $80,000 per year. However, this can vary depending on factors such as years of experience, certifications, and specific job responsibilities. Some Clinical Documentation Specialists may also receive bonuses and other benefits as part of their compensation package.
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Tenet Healthcare Corporation is a multinational investor-owned healthcare services company based in Dallas, Texas, United States.
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