Clinical Document Specialist

About the role

This role involves concurrent review of clinical documentation during patient stays to ensure accurate and complete records that support diagnoses, procedures, and severity of illness.

Responsibilities

• Collaborate with physicians and care teams to identify and clarify diagnoses.
• Conduct ongoing reviews of clinical documentation.
• Communicate findings through queries and reports.
• Use software tools for coding, abstracting, and reporting.
• Provide education to physicians and staff to improve documentation quality.
• Engage in process improvement initiatives.
• Analyze reports to support documentation accuracy.
• Maintain confidentiality in accordance with HIPAA guidelines.

Requirements

• Graduate of a nursing program.
• At least 1 year of related experience.

Qualifications

• Preferred credentials include RN licensure.
• Certifications in coding or documentation improvement are preferred.
• Strong communication, problem-solving, and coordination skills.
• Ability to work in a dynamic environment that may include rotating shifts, weekends, and holidays.