Job Description

Job Description

Job Description

WE ARE CORAL GABLES HOSPITAL

Our primary function is to offer continuous nursing, medical, and other health and social services on a 24-hour basis, under physician directed care and RN supervision.

We service a multitude of patients and their families across our vast network, while remaining committed to the professional development of our staff, the functional improvement of our patients, and the cultivation of strong partnerships within our communities.

WHAT WE OFFER

• Essential/stable and growing company with many opportunities for training and advancement within the medical field that all employees and team members (including Full-Time and Part-Time) can benefit from.
• Hourly pay is negotiable based on experience. We offer competitive market pay and opportunities for bonus depending on great work performance (bonuses only apply for Full Time).
• Comprehensive Employee Benefits: Full-Time employees are eligible for various plans for medical, dental, and vision insurance.

SUMMARY

We are seeking a knowledgeable clinical documentation specialist to oversee our facility's medical recordkeeping practices. In this role, you will be responsible for ensuring that clinical documentation complies with federal laws, training staff in medical recordkeeping practices, and analyzing medical information.

To ensure success, clinical documentation specialists should exhibit extensive experience in a similar role and sound knowledge of clinical documentation regulations. A first-class clinical documentation specialist should be a medical professional whose expertise translates into sound medical recordkeeping practices.

PRIMARY RESPONSIBILITIES

• Applying knowledge of medical terminology and procedures to evaluate clinical documents.
• Collecting medical information from healthcare providers and updating medical records.
• Verifying the accuracy of patient medical information and obtaining missing information.
• Monitoring diagnoses, treatments, and follow-up entries in medical records.
• Interpreting and preparing clinical reports for healthcare professionals and public health officials.
• Meeting with healthcare stakeholders to explain findings and facilitate actions.
• Ensuring that the content and storage of medical documents comply with federal laws.
• Training medical and administrative staff in standard medical recordkeeping procedures.
• Keeping abreast of advancements in the field of clinical documentation and changes in regulations.

Requirements

• Associate's or bachelor's degree in health information technology.
• Registered Health Information Technician (RHIT) preferred.
• Registered Nurse (RN) will be advantageous.
• Proficiency in Electronic Medical Record (EMR) software, such as eClinicalWorks and Praxis.
• A minimum of 3 years experience in a similar role.
• Advanced knowledge of best practices in medical recordkeeping.
• In-depth knowledge of medical terminology, coding, and procedures.
• Extensive experience in collecting and interpreting medical information, as well as training staff.
• Ability to keep informed of advancements and regulations in clinical documentation.
• Excellent organizational and communication skills.

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