The Clinical Documentation Specialist communicates with physicians, case managers, coders, and other health team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients; identifies opportunities for documentation improvement to ensure accuracy and completeness documentation used for measuring and reporting physician and hospital outcomes; provides education to all physicians and other clinicians related to compliant documentation responsibilities and coding and reimbursement issues; acts as consultant to coders when additional information or documentation is needed to assign the correct DRG.
Requirements
-BSN, RN and/or RHIA, RHIT, CCS required
-A minimum of five years of coding experience is preferred
-Working knowledge of Medicare reimbursement system and coding structures required
-Motivated, organized with excellent interpersonal communication skills, analytical skills, strong facilitation and presentation skills
-PC proficiency with Microsoft Word, Excel and 3M Encoder