Job Description:

The Clinical Documentation Specialist facilitates modifications to inpatient and/or outpatient clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all encounters.

Required Skills:

1. Professional, team player, able to communicate well with others. Strong interpersonal skills, pleasing personality, positive


2. Good critical thinking skills, able to assess, evaluate, and teach


3. Excellent verbal and written communication skills


4. Proficiency in organization and planning


5. Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching


6. Understanding of organizational policies and procedures


7. Working knowledge of quality improvement theory and practice


8. Ability and willingness to seek out and accept change


9. Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice


10. Knowledge of federal, state and private payer regulations


11. Knowledge of ICD-10 and MS-DRG, CPT-4, E&M, APC


12. Must possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching. 


13. Must demonstrate working knowledge of quality improvement theory and practice.


14. Knowledgeable of Federal, State, and other payers’ regulations, requirements, and criteria.


 

Required Experience:

Work Experience:

 

Three years of related clinical experience in an inpatient setting required.

  

Licensure/Certification:

 

Currently licensed as a Registered Nurse.

 

Certified Coding Specialist (CCS) or Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) preferred.

  

Education

 

BSN required.