CLINICAL DOCUMENTATION SPECIALIS

Clinical Documentation Specialist

Utilizes advanced knowledge and clinical expertise to direct efforts toward the improvement of clinical documentation through the roles of educator and consultant. Assists with facilitating improvement in the overall quality, completeness, and accuracy of medical record documentation. Through extensive interaction with physicians, nursing staff, and other patient caregivers, achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients. Assists with development and delivery of education for all members of the patient care team on documentation guidelines, coding, and reimbursement issues on an ongoing basis.

Skills and certifications include a Bachelor's Degree in Nursing or HIM AND 5 years experience, Associates in Nursing or HIT AND 10 years experience, RN, RHIA, RHIT or CCS, Certified Clinical Documentation Specialist (CCDS) preferred, experience in Critical Care, Utilization Management/Case Management, Clinical Documentation, ICD-10.

The ideal candidate will have a) a BSN and 5 years experience on a medical or surgical unit, b) a Bachelor's degree in HIM with 5 years experience in HIM/inpatient coding, c) Associates in Nursing and 10 years experience on a medical or surgical unit, or d) Associates in HIT and 10 years experience in acute inpatient coding. Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS). Certified Clinical Documentation Specialist (CCDS) preferred. Experience in Critical Care, Utilization Management/Case Management, Clinical Documentation, ICD-10 Coding Guidelines and DRG assignment or patient outcomes/quality management, preferred.

We are looking for a candidate with strong communication skills, written and verbal. The ideal candidate needs to be comfortable working independently in a collaborative, shared leadership environment.

Ideal candidate should have worked for the following company(ies): Other healthcare organizations comparable in size as either a nurse on a medical or surgical unit, or as a HIM/HIT professional with experience in inpatient coding.