Clinical Documentation Spec

Job Summary

This position is responsible for facilitating timely and accurate physician documentation in the medical record through concurrent chart review. Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders is key to the success of this position. This position is also responsible for ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines.

Job Requirements

• Education:
  • Required: Graduate of an approved nursing program
  • PREFERRED: Bachelor's Degree in Nursing
• Experience:
  • Required: 3 years acute care experience, 5 years preferred
  • PREFERRED: Preferred experience in (ED, ICU, Neuro or Stepdown)
• Skills:
  • Ability to apply coding guidelines when reviewing documentation in the medical record.
  • Ability to perform computer data entry.
  • Ability to work with others and communicate effectively.
• Licensure/Certification/Registration:
  • Required: Registered Nursing License
  • PREFERRED: CCDS or CDIP

Benefits

Medical, Vision, Dental, Retirement with Employer Match and more (20+ hrs/week). For a comprehensive list of benefits, please click here: Benefits | CoxHealth