Health Information Management Clinical Documentation Specialist (Sacramento)

POSITION TITLE: Health Information Management (HIM) Clinical Documentation Specialist

REPORTS TO (TITLE): Director of Health Information Management

DESCRIPTION OF POSITION:

To support the Health Information Management Department through a variety of clerical, technical and related support services. To dictate and edit Discharge Summaries for all physicians in an accurately and timely manner in accordance to hospital policy. 

KEY RESPONSIBILITIES:

·         Abstract and summarize patient information from the medical record to create hospital discharge summaries. 

·         Ensures medical record compliance by self-documentation attestation.

·         Prepares and sends all documentation to physician for review and approval via facility-specific procedures.  

·         Complies with hospital policies, including those relating to HIPAA and The Joint Commission.

·         This is an on-site position.

Requirements

POSITION Requirements:  

Knowledge and Experience:

·         High school diploma or equivalent required.  Bachelor degree in related healthcare field required.

·         Medical school graduate preferred.

·         2 years Health Information/Healthcare experience, experience in psychiatry required. 

·         Knowledge of medical terminology, with specific familiarity with psychiatric terminology preferred.

·         Advanced proficiency in operating medical record software preferred.

·         One year of required experience   in providing accurate and complete medical record documenation. ..

·         Demonstrated knowledge of patient privacy (HIPAA) relative to maintaining medical records required.

Skills and Abilities:

·         Maintains confidentiality of patient information at all times.

·         Sensitivity to and willingness to interact with persons of various social, cultural, economic and educational backgrounds.

·         Proficiency with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel and PowerPoint.)

·         Strong organizational skills with ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.

·         Strong written and verbal communication skills.

·         Strong interpersonal skills.  Ability to work with people with a variety of background and educational levels.

·         Ability to work independently and as part of a team.

·         Good judgment, problem solving and decision-making skills.

·         Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.

·         Ability to work in a fast-paced, expanding organization.

Physical Requirements:  

While performing the duties of this job, this position is frequently required to do the following: 

·         Use standard office equipment and access, input, and retrieve information from a computer.   Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time. 

·         Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population. 

·         Frequent bending, squatting, kneeling, climbing with the use of a step stool and twisting.  Lift and carry up to 20 pounds.

·         Sit or stand for minimum periods of one hour at a time.  Come and go from the work area repeatedly throughout the day.

·         Give and follow verbal and written instructions with attention to detail and accuracy. 

·         Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.

·         Vision: see details of objects at close range.

·         Coordinate multiple tasks simultaneously. 

Benefits

• Medical
• Vision
• Dental
• 401(k)
• 3.5 Weeks Paid Time Off
• $25,000 Life insurance policy is provided at no charge to the employee