Presbyterian Healthcare Services

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at Presbyterian Healthcare Services

Posted: 9/28/2020
Job Reference #: 12614

Job Description

Requisition ID
Default: Location : City
Location : Name
Presbyterian Hospital
Default: Location : State/Province (Full Name)
New Mexico


Assist providers with medical record documentation. Review physician documentation on a daily basis, track patient diagnosis and procedures to reflect the level of service provided. Daily interaction and collaboration with physicians and staff to ensure clinical information in the medical record is accurate to support the level of service rendered. This position may encounter resistance due to the perception that information is already adequately documented in the medical record. It requires experience and confidence to address all types of clinical documentation issues and regulatory requirements. The individual must be assertive and tactful to obtain medical staff cooperation.

Job Description
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: Yes
Work Schedule: Days


  • Responsible for clinical documentation analysis of the medical record, documentation completeness, coding accuracy and compliance in either electronic or hard copy form as designated.
  • Perform initial case reviews and appropriate follow-up reviews based on judgment of the clinical course of events.
  • Perform concurrent reviews of the medical record for inpatient admissions to include assignments of DRG, identifying complication and co-morbid conditions and specific co-existing conditions.
  • Document findings electronically, or hard copy worksheets if applicable, and records any identified key quality indicators, as appropriate.
  • Work collaboratively with the Medical Staff, Nursing Staff and other patient care givers to improve the quality of chart documentation to accurately reflect services provided.
  • Educate physicians of documentation requirements to support medical necessity for hospital and physician billing.
  • Present an accurate hospital and physician s profile, all diagnoses and procedures must be documented in the medical record and must properly reflect the level of services provided. Work with individual physicians to achieve this goal.
  • Timely communication with assigned service line physicians as assigned.
  • Interpret clinical information in the medical record, ordered interventions, lab and test results, etc., and queries if necessary for supporting documentation in progress notes, consultations, history and physicals, etc., as appropriate.
  • Initiate communication to physicians, providers, verbally or utilizing the appropriate prompter/query tools, in order to obtain more specific principal diagnosis or co morbidities and complications. Solicit clarification of existing documentation in the medical record that supports patients severity of illness.
  • Act as expert clinical resource for the HIM Coding team, working collaboratively to identify areas for clarification of documentation in the medical record that meets regulatory requirements to accurately reflect patient severity of illness and services provided.
  • Coordinate with the HIM Coding team related to coding guideline requirements for clinical documentation.
  • Collaborate with the HIM Coding team to provide information and education as necessary to physician and other providers not responding to prompters/ queries on documentation requirements.
  • Maintain and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. This includes but is not limited to all ICD-9, CPT-4, HCPCS and APC updates and changes. This includes but is not limited to CMS, JCAHO, Nursing Standards of Practice, etc.
  • Maintain up-to-date working knowledge of all PHS coding and documentation IT applications.
  • Maintain current knowledge of Nursing Practice through seminars, workshops, publications, etc.
  • Conduct training classes in areas of coding, documentation and compliance for physicians and other providers. This includes preparation of training materials, educational audits and answering situational questions.
  • Serve as a liaison to other departments, providing clinical expertise and consultation.
  • Utilizes monitoring tools to track defined measures for progress of documentation accuracy
  • Maintain accurate, detailed and organized records.
  • Ability to work independently and make independent decisions.
  • Ability to identify physician perceptions and/or concerns and act on this information in a tactful manner.
  • Able to maintain composure when dealing with physicians and hospital staff.
  • Problem solving and service as a role model and teach others in a non-threatening supportive manner.
  • Maintain positive interdepartmental relations and develop effective collegial collaboration.



Three to five years clinical experience in an acute care facility.
Experience with database, spreadsheet and word process required.
Knowledge of medical terminology, ICD-9, CPT, HCPCS and DRG required.
Knowledge of disease processes and related procedures.
Current knowledge of pathology and pharmacology impacts on care required.
Knowledge of conflict resolution techniques.


Registered Nurse - State of New Mexico or Compact State Nursing License required.

Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as CDS.

Education: Associate Degree in Nursing (BSN completion within 5 years of hire)


Benefits are effective day-one (for .45 FTE and above) and include:

  • Competitive salaries
  • Full medical, dental and vision insurance
  • Flexible spending accounts (FSAs)
  • Free wellness programs
  • Paid time off (PTO)
  • Retirement plans, including matching employer contributions
  • Continuing education and career development opportunities
  • Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.

Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.

Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.

New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.


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Application Instructions

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