Utilize advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation
Facilitate the overall quality, completeness, accuracy and integrity of medical record documentation
Participate in the development and delivery of education for providers and members of the healthcare team
Conduct concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation
Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care
Accurately code all relevant, appropriate and compliant working diagnoses codes
Maintain a working knowledge of applicable Federal, State and local laws and regulations

Associate/Diploma Degree in Nursing, or Health Information Technology (HIT)
Current Registered Nurse License in the State of practice, RHIA, RHIT, CCS, PA, NP/APN or completion of medical school
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred
Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing or as an inpatient coder preferred
Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills
Strong critical thinking skills and ability to integrate knowledge
Effective presentation/facilitation skills

Clinical Documentation Specialist

Key skills