Clinical Documentation Specialist

CommonSpirit Health • Lakewood, CO

13h • Onsite

About The Position

As our Clinical Documentation Specialist, you will facilitate and obtain appropriate physician documentation for clinical conditions or procedures, ensuring accurate severity of illness, expected risk of mortality, and complexity of patient care. Every day you will educate members of the patient care team (including physicians, allied health practitioners, nursing, and case management) on documentation guidelines and regulatory requirements. You will also support timely, accurate, and complete documentation, working independently with a high degree of autonomy, to ensure robust reporting of hospital and physician-based outcomes. To be successful in this role, you will possess expertise in clinical documentation improvement, a strong understanding of coding and regulatory requirements, excellent communication and educational skills, and the ability to work autonomously to optimize documentation integrity and support accurate outcome reporting.

Requirements

• Nursing Diploma or Associate's Degree
• Valid RN license from state of employment or from compact state
• Two (2) years of nursing experience in the inpatient hospital setting (critical care and/or strong med/surg experience preferred) or two (2) years nursing experience in the inpatient hospital setting and one (1) year of CDI experience
• Must demonstrate clinical competency through successfully passing Clinical Competency exam through Nuance
• Must demonstrate CDI software competency through passing CDEOne exam within two (2) months of starting role
• Proficient in use of Electronic Health Record

Nice To Haves

• BSN
• Experience in health information management or hospital quality program
• Clinical Documentation Specialist amd/or Certified Documentation Improvement Practitioner through American Health Management Association

Responsibilities

• Assists in improving the overall quality and completeness of physician clinical documentation by performing admission and continued stay reviews using clinical documentation improvement strategies and official coding guidelines.
• Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care rendered to patients.
• Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital and physician-based outcomes.
• Educates members of the patient care team including providers, nursing, case management, and other disciplines regarding documentation guidelines and regulatory requirements.
• Demonstrates knowledge of DRGs, hospital quality initiatives, clinical documentation requirements, and regulatory requirements.
• Able to effectively educate providers and other members of the healthcare team on clinical documentation, quality, and coding opportunities.

What This Job Offers

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