CLINICAL DOCUMENTATION SPECIALIST

Clinical Documentation Specialist

The RN Clinical Documentation Specialist conducts clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation of acute care services. He/she works with minimum supervision and must be self-motivated and demonstrates excellent initiative. This individual works closely with physicians and medical staff to facilitate appropriate physician documentation of patient care. He or she will play a key role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services. Previous CDI experience is highly desired. Case management experience is helpful. The selected candidate will be able to build a collaborative work environment with physicians, physician extenders, nurses, case managers and medical records coders.

Skills and Certifications

Associate's Degree in Nursing. Bachelors or Masters in Nursing Preferred

Competency in electronic clinical information systems

Ideal Candidate

The ideal candidate will be a Registered Nurse with previous Clinical Documentation Experience. Candidate must have worked in a Hospital Acute Care environment.