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Clinical Documentation Specialist Position Summary
The Clinical Documentation Specialist reviews inpatient medical records as directed on admission and throughout hospitalization. Will also analyze clinical status of patient, current treatment plan and past medical history and identify potential gaps in physician documentation. Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation. Demonstrates basic knowledge about HIM standards of coding and applies to ongoing evaluation of medical record documentation. Consistently meets established productivity targets for record review. Designs and implements, in collaboration with HIM Director and physician leadership, specific tools to support medical record physician documentation. Develops and implements plans in coordination with the CDI Manager, HIM Director and Coding Manager for both formal and information education of physicians, nursing and other clinical staff. Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation. Maintains good rapport and cooperative relationships and approaches conflict in a constructive manner. Helps identify problems, offers solutions and participates in their resolutions.
Clinical Documentation Specialist Position Requirements
Required experience:
Previous experience in inpatient coding and/or CDI experience.
Previous experience utilizing Microsoft Office products and EMR.
Registered Nurse license in the state in which you reside.
BSN required.
Minimum five (5) years experience as a Registered Nurse.