Clinic Documentation Specialist

Lake Regional Health System is seeking a Clinic Documentation Specialist to join our Coding team at our hospital campus located in the beautiful Lake of the Ozarks area. This is an exciting opportunity to utilize your experience and skills to make a real positive impact. As a highly regarded member of our health system, you will be proudly serving both patients and providers in our esteemed 121 bed hospital which is designated by the State as a Level II Trauma Center, Level II Stroke Center and Level II Stemi Center. With our state-of-the-art hospital and network of clinics, therapy sites, and pharmacies, Lake Regional offers a wide range of employment opportunities in our community.
Key Responsibilities

• Reviews concurrently selected populations of medical records to identify the principal and/or secondary diagnoses.
• Appropriately assigns the MS-DRG that most accurately reflects the severity of illness and risk of mortality of the patient based upon the clinical evidence documented at the time of the record review.
• Demonstrates knowledge and understanding of severity based DRG systems; All Patient
• Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
• Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
• Queries and Interacts with the physician and/or other designated members of the healthcare team as needed to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
• Works with other departments such as coding, corporate compliance, quality and finance to support Corporate Goals.
• Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members in an effort to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
• Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
• Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.

Qualifications/Requirements

• Bachelor's degree
• RN license preferred. Obtain and maintain CCDS or Coding certification within 2 years of employment.
• 5 years of related Nursing experience preferred.
• Knowledge of disease processes and clinical outcomes.
• Case Management and Strong financial and analytical skills.

Additional certifications may be required for this position and will be coordinated by Lake Regional as a part of your ongoing training and development. Please contact our recruitment team for more details.
Opportunity Features: Lake Regional offers a competitive compensation package that includes excellent benefits such as:

• Health, Dental, and Vision insurance
• Supplemental policies to fit your individual needs
• Employer-sponsored life and AD&D insurance
• Employee Assistance Program (EAP)
• Flexible Spending Accounts (FSA)
• 401K with a company match
• Paid Time Off (PTO)
• Tuition assistance and continuing education opportunities
• Area discounts
• And so much more!

If you'd like to be a part of a team setting that fosters excellence, apply now!