Job Description
Clinical Documentation Specialist Qualifications • Must have at least one of the following: o License to practice as a Registered Nurse preferred (any state) o Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist) • Must have all of the following: o 3+ years Acute Care (inpatient) and Concurrent Clinical Documentation Specialist experience o CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record. • Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and and highest level of SOI/ROM is achieved for the level of service rendered to all patients • Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis • Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities • Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses – obtaining missing information via a query when necessary Apply tot his job