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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