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Clinical Documentation Specialist

AnMed
Published
April 12, 2024
Location
Anderson, SC
Job Type
Work Setting
In-office

Description

AnMed is an independent, not-for-profit health system serving Upstate South Carolina and northeast Georgia. It is licensed for 601 beds and anchored by AnMed Medical Center, a 508-bed acute-care hospital that has earned the prestigious Magnet designation from the American Nurses Credentialing Center. The system also includes the Oglesby Specialty Inpatient Center, AnMed North Campus and AnMed Rehabilitation Hospital in Anderson, AnMed Cannon in Pickens and more than 60 physician practices. AnMed locations are spread from Easley to Hartwell, Georgia. More than 30 specialties are represented on staff. Named one of the nation’s 153 “Great Community Hospitals” by Becker’s Hospital Review, AnMed has more than 370 physicians and 3,600 employees, and it is Anderson County’s largest employer.

This position is responsible for performing concurrent review of the clinical documentation in the medical record within the Clinical Effectiveness program at AnMed.

Roles and Responsibilities 

  •  These duties include but are not limited to:  queries to the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality; thorough chart review to identify comorbidities/complications, and documents these appropriately on the documentation worksheet.
  • Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.
  • Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization.
  • Maintains the ability to be flexible, and prioritizes daily responsibilities.

Qualifications

  • Minimum of three to five years of clinical experience required with current SC license as RN.
  • Excellent communication and critical thinking skills.
  •  Computer experience required.
  • Ability to work independently and meet deadlines and schedules is required. Knowledge of care delivery documentation systems and related medical record documents.
  • Knowledge of age-specific needs and the elements of disease processes and related procedures.
  • Strong broad-based clinical knowledge and understanding of pathology/physiology.
  • Working knowledge of Medicare reimbursement system, coding structures, medical necessity criteria preferred, but not required.
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