Clinical Documentation Specialist
About The Position
This position is responsible for facilitating timely and accurate physician documentation in the medical record through concurrent chart review. Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders is key to the success of this position. This position is also responsible for ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines. Understand and utilization of ICD-10-CM and PCS coding assignment and follow Official Coding Guidelines.
Requirements
- Graduate of an approved nursing program
- 3 years of acute care experience
- Registered Nursing License
- Ability to apply coding guidelines when reviewing documentation in the medical record.
- Ability to perform computer data entry.
- Ability to work with others and communicate effectively.
Nice To Haves
- Bachelor's Degree in Nursing
- 5 years of acute care experience
- Experience in (ED, ICU, Neuro or Stepdown)
- CCDS or CDIP
Responsibilities
- Facilitating timely and accurate physician documentation in the medical record through concurrent chart review.
- Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders.
- Ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines.
- Understanding and utilization of ICD-10-CM and PCS coding assignment and following Official Coding Guidelines.
Benefits
- Medical
- Vision
- Dental
- Retirement with Employer Match
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
