The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical records documentation. Reviews and recommends opportunities for documentation improvement through extensive record review. Obtains appropriate clinical documentation through extensive interaction with physicians, patient care providers and the coding team to ensure the clinical documentation reflects the level of service rendered to the patient is complete and accurate. Educates members of the patient care team regarding documentation guidelines on an ongoing basis. Demonstrates knowledge and skills necessary to assign an accurate severity of illness
Work requires the knowledge of theories, principles and concepts normally acquired through completion of a Bachelor's degree in Nursing, Masters degree preferred, and 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) and Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Integrity Specialists or Certified Documentation Integrity Practitioner (CDIP) or Certified Coding Specialist (CCS) by the American Health Information Management Association within two years or hire.