Clinical Documentation Specialist Full Time 8:00AM - 4:30PM

Position Name: Clinical Documentation Improvement Specialist

Category: Support Department Case Management

Management: No

Schedule: Full Time 8:00AM - 4:30PM

Reports To: Director of Case Management

Summary:

• Performs on-site medical record reviews, by examining and assessing all patient documentation to ensure that all information including the illness diagnosis is accurate and facilitates improvement in the overall quality, completeness and accuracy of medical record documentation.
• This position interacts with physicians, Health Information Management (HIM) coding staff and other members of the health care team to ensure the accuracy and completeness of clinical documentation that supports resource utilization, length of stay and patient outcomes. On an ongoing basis, educate all members of the patient care team and participates in the development of educational tools and programs for the health care team.
• The individual will collect and analyze data to determine the effectiveness and efficiency of clinical documentation processes and physician participation.

Requirements:

• Preferred: Current CA RN, or RHIA/RHIT or CCS credential or experience in Case Management/Utilization review and familiarity with coding concepts preferred.
• Preferred: Knowledge of care delivery documentation systems and related medical records documents preferred
• Required: Has a broad based clinical knowledge and understanding of pathology/physiology of diseases processes required.
• Required: Current BLS required.
• Required: Must have experience working with computers.