Clinical Documentation Improvement Specialist, Hybrid (KY/IN Residents Only)

Responsibilities

The Clinical Documentation Improvement Specialist is a professional nurse accountable for the documentation management of a group of patients. The clinical documentation specialist focuses on safe effective patient care, customer satisfaction, and quality outcomes. They are responsible for assisting in maintaining a financially stable department, promoting their own development with an emphasis on evidence-based practice and education supported by a Practice Governance framework.

• Upon admission and concurrently throughout the inpatient stay, review the medical record for documentation that is ambiguous or nonspecific.
• Proactively engage the physician in discussion to clarify documentation to ensure the inpatient medical record accurately reflects the patient’s severity of illness and the intensity of services provided.
• Collaborate in the application of Core Measures to manage the care of targeted diagnoses within the system’s primary service lines.

This role offers a hybrid work option. Initial training will take place at a Norton Healthcare facility, and you must be available to come onsite for business needs as required. Employees in this position must reside in Kentucky or Indiana.

Qualifications

Required

• Three years in a critical care or medical-surgical hospital setting.
• Bachelor’s Degree (BSN) or Medical Degree.
• Registered Nurse (RN) credential required if education requirement is a BSN; RN not required if education requirement is a Medical Degree.
• Compact nursing license for Indiana and Kentucky.

Desired

• One year in case management and/or clinical documentation management.
• Bachelor’s Degree (BSN), Doctorate Degree, or Certified Clinical Documentation Specialist (CCDS) certification.