About The Position

The Clinical Documentation Specialist III is a senior technician responsible for improving the overall quality and completeness of clinical documentation. This role requires proficiency in all three grouper systems and expert knowledge of ICD-10 CM/PCS and all current regulations. The individual will facilitate modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Medical Records coding staff to ensure that documentation reflects a complete and accurate level of service rendered to patients. This role also assumes responsibility for the education of clinicians and project management as required.

Requirements

  • Proficiency in all three grouper systems.
  • Expert knowledge of ICD-10 CM/PCS and all current regulations.

Responsibilities

  • Improving the overall quality and completeness of clinical documentation.
  • Facilitating modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Medical Records coding staff.
  • Ensuring that documentation reflects complete and accurate level of service rendered to patients.
  • Education of clinicians.
  • Project management as required.
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