RN Clinical Documentation Specialist

RN Clinical Documentation Specialist

The RN Clinical Documentation Specialist is a clinical position using clinical/nursing knowledge of documentation requirements to improve overall quality and completeness of documentation in the patient's medical record using a multidisciplinary team approach. Works in collaborative effort with providers to ensure clinical information in the medical record is present and accurate, capturing the appropriate severity of illness and risk of mortality for the level of services provided and the appropriate DRG.

Essential Job Function:

• Initiates and performs documentation review (initial & follow up) of selected records to clarify conditions/diagnoses & procedures where inadequate or conflicting documentation exists in accordance with department standards.
• Ensures correct MS-DRG assignment, Severity of Illness (SOI)/risk of Mortality (ROM) scoring & identification of Hospital Acquired Conditions.
• Performs appropriate query process.
• Supports planning and educational processes of the Clinical Documentation Improvement Program.
• Develops and maintains effective working relationships with colleagues and communicates effectively with multidisciplinary teams.
• Meet established departmental goals/standards.
• Performs other duties as assigned.

Education:

• Required: Bachelor's Degree in Nursing.

Experience:

• Required: 3 years.

Licensure/Certification/Listing:

• Required: Registered Nurse licensed in NC or compact State Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP), If not certified, CCDS or CDIP must be completed within 1 year after eligibility period met.