Job Description

Clinical Documentation Specialist RN

Job Description This position is 100% onsite, to allow for better communication and coordination with our staff and providers. The Clinical Documentation Specialist (CDS) performs clinical documentation improvement activities in an effort to support accuracy and quality of the patient records and to ensure that coded diagnoses are an accurate reflection of the patient's clinical status and care. The role of the CDS involves reviewing the medical record documentation and clinical indicators and working with providers to ensure a complete and accurate medical record. The CDS will identify potential gaps in clinical documentation for inpatient and payer populations as directed throughout the hospitalization. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Skills and Experience: Must possess a current, valid RN license or an RHIA, RHIT, or CCS credential. Minimum five years acute hospital nursing experience (e.g. medical/surgical unit, intensive care). Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding strongly desired. Minimum one-year auditing experience strongly desired. ICU/Critical Care experience strongly desired. Prior experience in clinical documentation improvement, ICD coding, and MS-DRGs preferred. Prior experience educating physicians/providers preferred. Prior experience in a clinical documentation improvement department or as a consultant strongly desired. Must possess a comprehensive knowledge of medical terminology, disease processes, and clinical competency. INDPR

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