Clinical Documentation Specialist

Job Summary and Responsibilities

You will work under indirect supervision, facilitating and obtaining appropriate physician documentation for clinical conditions or procedures to support the severity of illness, risk of mortality, and complexity of care.

• Educate members of the patient care team regarding documentation guidelines and regulatory requirements.
• Support timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital and physician-based outcomes.
• Work independently with a high degree of autonomy.

Job Requirements

• Education Requirements: Nursing Diploma or Associates Degree, BSN preferred.
• Licenses/Certifications: Current RN license in state of employment or valid RN license from compact state, required; CCDS, CDIP preferred.
• Experience Requirements: Three years of nursing experience in an inpatient hospital setting (critical care and/or strong med/surg experience preferred), or two years of nursing experience in an inpatient hospital setting and one year of CDI experience.
• Competencies: Successfully pass Clinical Competency exam through Nuance, pass Clintegrity exam within six months of starting role, proficiency with MS Office software, proficient in using Electronic Health Record, experience in health information management or hospital quality program preferred, self-motivated with excellent interpersonal, critical thinking, analytical, organizational, and writing skills.

Physical Requirements

Sedentary work -(prolonged periods of sitting and exert up to 10lbs force occasionally)