Compliant Documentation Specialist

Marshall Health Network • Huntington, WV

11d

About The Position

The Compliant Documentation Specialist (CDS) reviews medical records to support accurate representation of the severity of illness. The role involves extensive record review and interaction with physicians, HIM professionals, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Improvement Program (CDIP) process are key parts of the position.

The specialist applies clinical expertise in the area of responsibility and patient management, along with knowledge of pathophysiology and disease processes. The role also requires understanding and supporting DRG documentation strategies and, after training, navigating CDI software. The shift is determined by each hiring manager, and pay is determined in accordance with the labor agreement.

Requirements

• At least 2 years of Adult ICU experience.
• Must be a Registered Nurse in West Virginia or be able to obtain a West Virginia RN license by the hire date.
• Bachelor's degree with a clinical background.
• At least 5 years of position-related experience.
• Minimum experience includes hospital-setting patient care and direct knowledge of care management, resource management, compliant documentation improvement, coding, DRG assignments, and ICD-9/10.
• Clinical expertise in the area of responsibility and patient management.
• Excellent organizational, analytical, writing, and interpersonal skills; ability to build effective relationships with the healthcare team.
• Critical-thinking, problem-solving, and deductive-reasoning skills.
• Clinical and leadership skills and performance-improvement knowledge.
• Knowledge of DRGs and basic computer skills, including familiarity with Windows-based software programs.
• Dependable, self-directed, and pleasant.

Nice To Haves

• Compliant Documentation Improvement Specialist Certification is preferred.
• Recent hospital experience in ICU or CCU.

Responsibilities

• Review medical records to facilitate accurate representation of severity of illness.
• Interact with physicians, HIM professionals, and nursing staff as part of record review and documentation improvement.
• Participate in team meetings.
• Educate staff about the CDIP process.
• Understand and support DRG documentation strategies.
• Navigate the CDI software product after completing training.

What This Job Offers

• Job Type: Full-time