Clinical Documentation Specialist - Medical Records

St. Peter's Health Regional Medical Center • Helena, MT

1d

About The Position

This position provides concurrent clinical review of inpatient medical records to ensure accurate and complete documentation of diagnoses and procedures. Reviews clinical information, assigns appropriate codes, supports quality assurance and reporting efforts, and provides education to providers and staff on clinical documentation. Requires excellent communication skills, strong attention to detail, and the ability to build positive relationships with physicians while providing guidance in a respectful, non-confrontational manner.

Requirements

• Excellent communication skills
• Strong attention to detail
• Ability to build positive relationships with physicians
• Provide guidance in a respectful, non-confrontational manner
• High level of accuracy required

Nice To Haves

• RN license with at least 3 years of clinical experience
• 2 years previous clinical documentation experience
• Clinical Documentation Specialist or Inpatient Coding Certification
• Experience may be considered in lieu of certification

Responsibilities

• Concurrent clinical review of inpatient medical records
• Ensure accurate and complete documentation of diagnoses and procedures
• Review clinical information
• Assign appropriate codes
• Support quality assurance and reporting efforts
• Provide education to providers and staff on clinical documentation

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree