Clinical Documentation Specialist RN
About The Position
As a Clinical Documentation Specialist, you will provide critical expertise in medical record accuracy and integrity, profoundly impacting patient care quality and financial compliance. Every day you will expertly review clinical documentation, query physicians for clarity and specificity, educate providers on documentation best practices, and meticulously ensure all records accurately reflect the patient's severity of illness and complexity of care. To be successful, you will demonstrate outstanding analytical skills, strong knowledge of clinical coding guidelines, and a collaborative, detail-oriented demeanor, contributing to precise data, appropriate reimbursement, and improved patient outcomes.
Requirements
- Associates degree in Nursing required
- Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU, upon hire
- Registered Nurse: TX, upon hire
Responsibilities
- Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies
- Accurate and timely record review
- Recognize opportunities for documentation improvement
- Initiates CDMP severity Worksheet for inpatients
- Formulate clinically credible documentation clarifications
- Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
