CLINICAL DOCUMENTATION SPECIALIST
About The Position
Position Purpose The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review. Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. What you will do Assist in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes Communicate with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement Conduct concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness Maintain a working knowledge of applicable Federal, State and local laws and regulations and accrediting agencies Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care
Requirements
- Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.
- Must possess one of the below: Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) required, licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
- Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.
- Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.
- Strong critical thinking skills and ability to integrate knowledge.
- Prioritization and organizational skills required.
- Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
Nice To Haves
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
- Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.
Responsibilities
- Assist in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes
- Communicate with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement
- Conduct concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation
- Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness
- Maintain a working knowledge of applicable Federal, State and local laws and regulations and accrediting agencies
- Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care
Benefits
- Full time 40hr M-F
- Great benefits and Health Insurance Coverage
- Local Residency not required
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
