Job Description

Clinical Documentation Specialist Qualifications

Must have at least one of the following:

o License to practice as a Registered Nurse preferred (any state)

o Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)

Must have all of the following:

o 3+ years Acute Care (inpatient) and Concurrent Clinical Documentation Specialist experience

o CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required

Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.

Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and and highest level of SOI/ROM is achieved for the level of service rendered to all patients

Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis

Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities

Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses obtaining missing information via a query when necessary

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