Clinical Documentation Specialist

Role Overview

• Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care
• Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation
• Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes

Requirements

• Graduate of an accredited school of nursing OR Foreign trained physician
• RN-Registered Nurse of California OR Foreign trained physician
• 5 years recent relevant experience
• CDIP or CCDS preferred
• Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications
• Knowledge of age-specific needs and the elements of disease processes and related procedures
• Knowledge of current coding classification and reimbursement guidelines and regulations
• Critical thinking with the ability to analyze and interpret medical record/clinical documentation and formulate appropriate physician queries
• Ability to define issues, collect data, establish facts and draw valid conclusions
• Collaboration skills to facilitate open sharing of information and cooperation with various stakeholders to problem solve and achieve desired results/outcome
• Displays a customer service focus in all decisions and actions
• Ability to communicate through verbal and written means, and to present information to a variety of audiences
• Ability to create and translate data into reports and presentations for appropriate audience
• Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines while maintaining a high degree of responsiveness
• Ability to interact and maintain effective working relationships with those contacted in the performance of required duties
• Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment
• Demonstrates initiative in providing feedback/input to improve workflow/processes
• Ability to work effectively in a dynamic and fast-paced environment with changing business priorities
• Ability to maintain and work discreetly with confidential information
• Ability to use essential applications and/or databases associated with the role’s duties and responsibilities.

Benefits

• Yes