Clinical Documentation Specialist-Medical Records-FT-1st shift

Huntsville Hospital Health System • Huntsville, AL

9d

About The Position

The Clinical Documentation Improvement Specialist (CDIS) implements clinical documentation improvement activities to support the accuracy and quality of patient records and ensure coded diagnoses accurately reflect patients’ clinical status and care. The specialist reviews medical record documentation and clinical indicators and works with providers to ensure complete and accurate records. Accurate documentation supports patients, continuity of care by subsequent providers, and demonstration of high-quality care by physicians and the hospital.

The specialist identifies potential clinical documentation gaps for inpatient and payer populations as directed throughout hospitalization. The role also includes educating physicians and other key healthcare providers about clinical documentation improvement and the need for accurate and complete health records.

Requirements

• At least one of the following: BSN, RN, or a comparable clinical degree.
• At least five years of acute hospital nursing experience, such as medical/surgical unit or intensive care experience.
• Comprehensive knowledge of medical terminology, disease processes, and clinical competency.
• Excellent verbal and written communication, interpersonal, collaboration, and relationship-building skills.
• Strong critical thinking skills and the ability to integrate knowledge.
• Prioritization and organizational skills.
• Ability to educate members of the healthcare team about clinical documentation.
• Data quality and integrity skills.
• Strong working knowledge of word processing, spreadsheet, and reporting software.
• English proficiency for verbal and written communication, with the ability to communicate effectively at a high level.

Nice To Haves

• Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management, and/or inpatient coding.
• Prior experience in clinical documentation improvement, ICD coding, and MS-DRGs.
• Prior experience educating physicians/providers.
• Previous experience working in a clinical documentation improvement department or as a consultant.
• At least one year of auditing experience.
• Experience with encoder software, clinical documentation improvement software, and the electronic medical record.
• RHIT, RHIA, CDIP, CCDS, CCS, and ICD-10 certification or designation.

Responsibilities

• Implement clinical documentation improvement activities to support accurate and high-quality patient records.
• Review medical record documentation and clinical indicators and work with providers to ensure complete and accurate records.
• Identify potential clinical documentation gaps for inpatient and payer populations as directed throughout hospitalization.
• Educate physicians and key healthcare providers about clinical documentation improvement and the importance of accurate, complete health records.

What This Job Offers

• Job Type: Full-time