Clinical Documentation Specialist - Health Information Management (Full Time) - 7184

Responsibilities

• Ensure accurate and appropriate physician documentation in the patient medical record to support DRG assignment by the coding staff.
• Facilitate the accurate representation of the severity of illness and risk of mortality in the patient record.
• Perform extensive medical record review.
• Interact with physicians, nurse practitioners, physician assistants, and HIM professionals.
• Query physicians and other clinicians to obtain additional documentation as necessary to accurately describe the patient’s condition.
• Complete chart reviews for medical necessity.
• Communicate educational information to physicians regarding clinical documentation improvement matters and the importance of accurate and complete documentation.

Qualifications

• Bachelor’s degree in Nursing or related field required.
• Current RN license in good standing.
• Minimum 5 years of nursing experience, preferably in a healthcare setting.
• Experience with medical terminology and coding systems.
• Strong communication skills, both written and verbal.
• Ability to work independently and as part of a team.
• Proficiency in electronic health records (EHR).