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WakeMed Health & Hospitals
Raleigh, North Carolina
Northeast Georgia Health System
Gainesville, Georgia
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Clinical Documentation Specialist
PRIMARY FUNCTION: Responsible to ensure that health care services are administered with quality, cost efficiency, and within compliance, along with improving and ensuring the overall quality, cost efficiency and completeness of documentation within the inpatient medical record. Continuously reviewing and auditing patient medical records (observation and inpatients), screening for unnecessary procedures, ineffective treatments, and unnecessarily extensive hospital stays. Educates members of the patient care team on documentation guidelines on an ongoing basis. Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, coding staff and other members of the healthcare team to support the approp
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