Clinical Documentation Specialist

At VEBT, employees are our No. 1 investment. We are looking for a high functioning, detail-oriented professional who can juggle various tasks with accuracy and is interested in molding their career with an award-winning, growing company.

Duties and Responsibilities

- Conducts initial and follow up concurrent reviews of medical records for assigned patients in the time frame and frequency defined for productive work.

- Participates in all coding education on ICD-10, MS-DRG and quality outcome measures as well as compliance requirements related to query.

- Navigates the electronic medical record system to abstract concurrent and retrospective data on all patients meeting data guidelines.

- Works closely with the medical staff and other healthcare team member to help identify potential gaps in physician documentation and ensuring appropriate reimbursement is received for the level of service rendered to all patients.

- Finds, reads and comprehends H&Ps, discharge summaries, progress notes, procedures notes, labs, medications, and outside medical records.

Qualifications

Bachelor's degree in Nursing or Health Information Management is required. 

Minimum of 3 years in recent acute care hospital setting along with experience Clinical Documentation
Knowledge of care delivery documentation systems and related medical record documents.

This is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, ancestry, age, physical or mental disability, sex, sexual orientation, gender identity/expression, pregnancy, veteran status, marital status, creed, status with regard to public assistance, genetic status or any other status protected by federal, state or local law.