Under the immediate supervision of the Director of Quality Management, the Clinical Documentation Reviewer oversees the healthcare organization's medical recordkeeping practices. This includes ensuring compliance with federal laws, staff training, and analyzing medical information to meet payment requirements.
- Minimum 3 years in healthcare, preferably behavioral health.
- Associate or bachelor’s degree in a healthcare-related field.
- Registered Health Information Technician (RHIT) preferred.
- Registered Nurse (RN) a plus.
- Proficient in EMR software like eClinicalWorks and My Avatar.
- In-depth knowledge of medical terminology and procedures.
- Experience in collecting and interpreting medical information.
- Excellent organizational and communication skills.
- Evaluate clinical documents using medical terminology knowledge.
- Review medical information, update records to meet regulations.
- Verify accuracy of patient data, obtain missing information.
- Monitor diagnoses, treatments, and follow-up entries.
- Ensure proper documentation practices.
- Prepare clinical reports for healthcare professionals.
- Meet with stakeholders to explain findings.
- Ensure medical document compliance with federal laws.
- Train staff in medical recordkeeping procedures.
- Stay updated on clinical documentation advancements and regulations.
- Analytical Thinking: Break down complex problems into manageable components, make logical conclusions, and anticipate obstacles.
- Auditing: Systematically gather and evaluate audit evidence.
- Budget Development: Compile and analyze financial data, allocate funds.
- Communication Effectiveness: Convey information clearly to engage and inform.
- Compliance: Ensure adherence to regulations and policies.
- Ethical: Apply ethical decision-making grounded in social work values.
- Financial Management: Manage department's financial structure.
- Leadership: Utilize organization's mission and vision for team excellence.
- Personal Effectiveness/Creditability: Represent organization with high standards.
- Professionalism: Demonstrate respectful and effective relationships.
- Report Generation: Gather and present information in comprehensive reports for intended audiences.