What are the responsibilities and job description for the Clinical Documentation Specialist position at Hillsdale Hospital?
Work Schedule
7:30-16:00 Monday through Friday on-site at the hospital, not remote
Qualifications
- Required: Associates Degree in nursing, State of Michigan Registered Nurse license
- Preferred: Bachelors’ degree in Nursing, RHIA, RHIT, CCDS or combination thereof
- 2-4 years clinical experience required, preferred ICU, ER or other critical area
- Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
- Works independently with proven organizational skills and attention to detail
- Must be able to prioritize multiple tasks and exercise sound judgment
- Demonstrates proficiency in verbal and written communication skills
- Excellent interpersonal skills and the ability to interact effectively and professionally with individuals at all levels; both internal and external
- Must be proficient in Microsoft Office (Word, Excel and PowerPoint)
- Coding experience preferred
Responsibilities
- Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the clinical documentation improvement strategies
- Performs accurate and timely medical record review
- Recognizes opportunities for documentation improvement
- Initiates clinical documentation improvement severity worksheet for inpatients
- Formulates clinically credible documentation clarifications
- Requests documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety
- Has effective and appropriate communication with physicians
- Follows up timely on all cases and resolution of those cases with clinical documentation clarifications
- Participates in Task Force Meetings
- Manages multiple priorities efficiently
- Communicates with HIM coding staff and resolves discrepancies
- Accurately inputs data into electronic clinical documentation improvement tool
- Perform other duties as required or assigned
Benefits
- Insurance: medical, prescription, dental, vision, life, disability
- Paid Time Off: vacation, sick days, personal days, holidays
- Retirement: 403(b) with match
- Education assistance and continuing education
Why Hillsdale Hospital
- Hillsdale Hospital is dedicated to excellence in healthcare community service, continued improvement, and respect for human life. We manage the health needs of our local community through compassionate and highly skilled care in our clean, safe, healing environment.
- Hillsdale Hospital is a 2022, 2023, and 2024 Detroit Free Press Top Workplace in Michigan and a USA Today Top Workplaces 2025!
Equal Opportunity Employer
