Clinical Documentation Specialist

Role Overview

• Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant.
• Facilitates the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review.
• Participates in the development and delivery of education for providers and members of the healthcare team.
• Conducts concurrent reviews of selected patient records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.
• Communicates documentation discrepancies and coding definitions to the physicians both written and verbally as needed to clarify clinical documentation in accordance to query standards and/or policies.
• Collaborates with the multi-disciplinary team regarding clinical documentation issues.
• Utilizes computer systems effectively and maintains record of reviews completed, queries completed and outcome of physician response.

Requirements

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or an Advanced degree in nursing (NP/APN) or Physician Assistant.
• In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist.
• Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Professional (CDIP) or Certified Coding Specialist (CCS) will be considered in lieu of a RN.
• Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), or as an inpatient coder preferred.

Benefits

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement.
• Relocation assistance (geographic and position restrictions apply).
• Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing.
• Employee Referral Rewards program.
• Mount Carmel offers DailyPay
• if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday.
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.