We are Prisma Health.

Greenville Health System and Palmetto Health have come together to create Prisma Health. We’re excited to be united under one name. Together, we are looking at health in a completely new way. Prisma Health is the largest not-for-profit health organization in South Carolina, serving more than 1.2 million patients annually. Our 30,000 team members are dedicated to living our promise: Inspire health. Serve with compassion. Be the difference.

The Clinical Documentation Specialist is responsible for facilitating the accurate representation of the severity of illness and risk of mortality by improving the quality, completeness, and accuracy of the physicians' clinical documentation through extensive medical record review and query process. Through active engagement and interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients.

All team members are responsible for bringing life to our Purpose Statement – Inspire health. Serve with compassion. Be the difference – through every action and every interaction at work.

Responsibilities:

• ·         Conducts concurrent medical record reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.
• ·         Assists in overall quality, timeliness, and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes.
• ·         Collaborates with care givers to ensure appropriate documentation to support the clinical picture and level of severity to inpatients for DRG-based payors.
• ·         Queries physicians to obtain accurate documentation related to specificity of ICD-10 coding, severity of condition, co-morbidities, and length of stay.
• ·         Maintains proficient knowledge of assessment, clinical disease process, and treatment.
• ·         Supports timely accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes data.
• ·         Demonstrates the ability to develop and maintain supportive, collaborative relationships with physicians to include education and follow up.

Education: Associate's degree in Nursing or Health Information Management.

Experience: Minimum of 2 years of experience in adult medical/surgical/critical care/ER/PACU nursing, clinical documentation improvement, or inpatient coding.

Licensure, Registry, or Certification: One of the following required: LPN, RN, BSN, RHIT, RHIA, CCS, CCDS, or CDIP. Current BLS (Basic Life Support for Healthcare Providers) required prior to start date directly through the American Red Cross, the American Heart Association, or the military. (To register: Blended Learning or In Person BLS through the American Red Cross; or Classroom or Skills Session BLS through the American Heart Association. Certification must include an in-person skills session.

All your information will be kept confidential according to EEO guidelines.

To learn more check out our career page www.Prismahealth.org/midlandscareers