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.
Ability to read and communicate in the English language. 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.
5 years of experience required