Medical Records

Cookeville Regional Medical Center

HIM Tech Apply

This position is responsible for clerical functions in the Medical Record Department.  Exact job assignment may differ, but may include but are not limited to prepping, scanning and indexing documents, retrieval of records, reception/phone duties, preparation of birth certificates, and entering information in the computer system.

EDUCATION:  High school diploma

EXPERIENCE:  At least 6 months experience in a clerical setting is preferred.

SKILLS:  Must possess excellent computer skills, proficient keyboard skills, knowledge of general office procedures and equipment.  Works under limited supervision, must be able to organize work, flexibility enabling attention to variable duties and frequent interruptions.  Preferences for activities that are constant and repetitive, aptitude for clerical perception to perceive differences in any copy, to proofread words and numbers in order to minimize error.  Must possess ability to work well under pressure.  Cooperative, congenial, and positive behavior exhibited.  Behavior and personal appearance reflecting a good image of Cookeville Regional Medical Center.


Clinical Documentation Specialist Apply

This position is responsible for reviewing medical records to facilitate appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Working with providers to improve the quality of clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignments and clinical conditions or procedures. Educates members of the patient care team, regarding documentation guidelines, including  all physician and extenders. Evaluates patient levels of care in conversation daily, and queries medical staff as needed to insure patients meeting inpatient status are converted appropriately. Ensures the timeliness of all written and verbal queries from providers to ensure proper documentations obtained and placed in the medical record before patient discharge. Maintains communication with physician office to provide education. Reports to Corporate Compliance and manages outliers.

1. EDUCATION: Tennessee Registered Nurse License, BSN preferred, or Registered Health Information Administrator with coding/CDI certification preferred.

2. EXPERIENCE:  Three to five years registered nurse clinical experience in similarly complex acute care setting. Familiarity with utilization review, case management, nurse review activities or coding experience preferred. RHIA candidate: . Requires minimum three years previous validation experience and five plus years of coding and clinical documentation experience with extensive clinical knowledge in an acute hospital environment.

RN - Must be knowledgeable in:, (CD-10-CM/PCS -MS-DRGs, DRGs knowledge or use of InterQual criteria and clinical guidelines for admitting patients to the hospital.

Both RHIA and RN - Requires excellent and comprehensive knowledge of anatomy, physiology, as defined by the Medical Diagnostic Categories and all body systems. Strong background knowledge of disease process and pharmacology. . SKILLS:  Knowledge of general office procedures, proficient computer skills in Microsoft Office  required. Demonstrates a high level of communication with clinical and administrative staff. Ability to effectively communicate with all Hospital practitioners. Possesses excellent written, oral communication and interpersonal skills. Must be conversant in clinical documentation improvement.  High level of proficiency in adult education and training to develop and conduct ongoing CRMC CDI education for staff, including new clinical documentation specialists, coders, physicians, residents, nursing and allied health professionals. Participates in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

Must be self-sufficient, reliant and able to work well with others. Must be flexible and willing to accept and adapt to constant change due to changes enforced upon providers by Federal government/CMS local coverage determinations and national coverage determinations changes.

 Requires knowledge of clinical pertinence requirements and proficiency in abstraction and data entry into the entire data base systems used for clinical documentation. Must be able to read and interpret electronic and manual documentation generated by healthcare professionals.

Active CDIS certification or achievement expected within two years of employment.