Clinical Documentation Specialist

Job summary

Responsible for ensuring that clinical documentation accurately reflects the services and care provided to patients. Acts as a coordinator of physician clinical documentation, coding, and reimbursement processes.

Job details

Day (United States of America) Department: 100 - 820000 TG - Hospital Information Management Position Description: Responsible for ensuring that clinical documentation within the health system accurately reflects the services and care provided to patients and is consistent with the criteria for high-quality clinical documentation, Acts as a coordinator of physician clinical documentation, coding and reimbursement processes in working towards agreed upon quality and productivity targets for all services in the system. Identifies, monitors, and reports opportunities for quality and performance improvement to the appropriate department. Takes an active role in performance improvement activities as it relates to documentation improvement. Qualifications: ICD-9CM hospital-based coding experience preferred. Credentialed as an RN, LPN, PA, NP, RHIA, RHIT, or CCS required. Case Management/Utilization review experience preferred. Certification as a CCM, CPHQ preferred. Critical care or strong medical/surgical background required or surgical background if assigned to surgical areas; 3-5 years in clinical practice preferred. Familiar with government healthcare reimbursement systems. Have experience working collaboratively with diverse groups in a healthcare environment. Be successful in interacting effectively with physicians. Basic computer literacy is required; experience with Windows, word processing, spreadsheets, graphics, and databases is preferred. Have the ability to analyze large amounts of data to identify trends. Experience with writing technical reports is desirable.

What you’ll do

Responsible for ensuring that clinical documentation accurately reflects the services and care provided to patients. Acts as a coordinator of physician clinical documentation, coding, and reimbursement processes.

Requirements

ICD-9CM hospital-based coding experience is preferred, along with relevant credentials such as RN, LPN, PA, NP, RHIA, RHIT, or CCS. A critical care or strong medical/surgical background is required, along with experience in government healthcare reimbursement systems.

Listed skills

• Data analysis · Preferred

Other relevant skills

Identified from the job description. Confirm important requirements above.

• Clinical Documentation
• Coding
• Reimbursement Processes
• Quality Improvement
• Performance Improvement
• ICD-9CM Coding
• RN
• LPN
• PA
• NP
• RHIA
• RHIT
• CCS
• Case Management
• Utilization Review
• Data Analysis
• Technical Writing

Job areas

• Healthcare
• Administrative