Clinical Documentation Spec

Description

• Job Summary

◦ This position is responsible for facilitating timely and accurate physician documentation in the medical record through concurrent chart review. Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders is key to the success of this position. This position is also responsible for ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines. Understand and utilization of ICD-10-CM and PCS coding assignment and follow Official Coding Guidelines.

◦ Education

▪ Required : Graduate of an approved nursing program

▪ Preferred : Bachelor's Degree in Nursing

◦ Experience

▪ Required : 3 year’s acute care experience, 5 years preferred

▪ Preferred : Preferred experience in (ED, ICU, Neuro or Stepdown)

◦ Skills

▪ Ability to apply coding guidelines when reviewing documentation in the medical record.

▪ Ability to perform computer data entry.

▪ Ability to work with others and communicate effectively.

◦ Licensure / Certification / Registration

▪ Required : Registered Nursing License

▪ Preferred : CCDS or CDIP◦ Education ▪ Required : Graduate of an approved nursing program ▪ Preferred : Bachelor's Degree in Nursing ◦ Experience ▪ Required : 3 year’s acute care experience, 5 years preferred ▪ Preferred : Preferred experience in (ED, ICU, Neuro or Stepdown) ◦ Skills ▪ Ability to apply coding guidelines when reviewing documentation in the medical record. ▪ Ability to perform computer data entry. ▪ Ability to work with others and communicate effectively. ◦ Licensure / Certification / Registration ▪ Required : Registered Nursing License ▪ Preferred : CCDS or CDIP