Nurse Clinical Documentation Specialist

Facilitate improvement in the overall quality, completeness, and accuracy of medical record documentation Review records and recommend opportunities for documentation improvement Interact extensively with physicians, patient care providers, and the coding team Ensure clinical documentation reflects the level of service rendered and is complete and accurate Educate patient care team members on documentation guidelines on an ongoing basis Assign accurate severity of illness Requirements Bachelor's degree in Nursing required Master's degree preferred Three to five years of previous work-related experience in Medical/Surgical, Intensive Care, Emergency Department, or PACU Medical school graduate (MD, MBBS) or Registered Nurse (RN) Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Integrity Specialists, Certified Documentation Integrity Practitioner (CDIP), or Certified Coding Specialist (CCS) by the American Health Information Management Association within two years or hire Knowledge of theories, principles, and concepts related to clinical documentation Ability to review medical records and assign accurate severity of illness Core Competencies Demonstrates expertise in clinical documentation improvement, ensuring accuracy and completeness of medical records while educating healthcare teams on documentation guidelines. Proficient in assessing severity of illness and collaborating with medical professionals to enhance documentation practices. Highest-signal resume keywords Clinical Documentation Improvement Medical Record Review Certified Clinical Documentation Specialist (CCDS) Registered Nurse (RN) Severity of Illness Assessment Hard Skills Clinical Documentation Medical Record Review Documentation Guidelines Severity of Illness Assignment Quality Improvement Soft Skills Interpersonal Communication Team Collaboration Education and Training Certifications & Qualifications Certified Clinical Documentation Specialist (CCDS) Certified Documentation Integrity Practitioner (CDIP) Certified Coding Specialist (CCS) Industry Keywords Medical/Surgical Intensive Care Emergency Department PACU Clinical Documentation Integrity #J-18808-Ljbffr Jobtailor