A Bachelor's degree in Nursing or Health Information Management and five years of experience, or an associate degree in Nursing or Health Information Technology and ten years of experience.
A current Registered Nurse license in the state of practice, Registered Health Information Administrator certification, Registered Health Information Technologist certification, or Certified Coding Specialist certification.
Experience in critical care, utilization management or case management, clinical documentation, and International Classification of Diseases, Tenth Revision coding.
Strong written and verbal communication skills.
Ability to work independently in a collaborative, shared-leadership environment.
Responsibilities
Use advanced clinical knowledge and expertise to direct efforts to improve clinical documentation as an educator and consultant.
Assist with improving the quality, completeness, and accuracy of medical record documentation.
Interact extensively with physicians, nursing staff, and other patient caregivers to achieve appropriate clinical documentation supporting medical necessity and the level of services rendered to patients.
Assist with developing and delivering ongoing education for the patient care team on documentation guidelines, coding, and reimbursement issues.
Experience in critical care, utilization management or case management, clinical documentation, International Classification of Diseases, Tenth Revision coding guidelines, diagnosis-related group assignment, or patient outcomes and quality management.
Five years of experience as a registered nurse on a medical or surgical unit, or in Health Information Management or inpatient coding with a bachelor's degree.
Ten years of experience as a registered nurse on a medical or surgical unit, or in acute inpatient coding with an associate degree.
Job Description
CLINICAL DOCUMENTATION SPECIALIST
5+ to 7 years experience
Utilizes advanced knowledge and clinical expertise to direct efforts toward the improvement of clinical documentation through the roles of educator and consultant. Assists with facilitating improvement in the overall quality, completeness, and accuracy of medical record documentation. Through extensive interaction with physicians, nursing staff, and other patient caregivers, achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients. Assists with development and delivery of education for all members of the patient care team on documentation guidelines, coding, and reimbursement issues on an ongoing basis.
SKILLS AND CERTIFICATIONS
Bachelor's Degree in Nursing or HIM AND 5 Years Experience
Associates in Nursing or HIT AND 10 Years Experience
Experience in Critical Care, Utilization Management/Case Management, Clinical Documentation, ICD-10
IDEAL CANDIDATE
The ideal candidate will have a) a BSN and 5 years experience on a medical or surgical unit, b) a Bachelor's degree in HIM with 5 years experience in HIM/inpatient coding, c) Associates in Nursing and 10 years experience on a medical or surgical unit, or d) Associates in HIT and 10 years experience in acute inpatient coding.
Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS). Certified Clinical Documentation Specialist (CCDS) preferred.
Experience in Critical Care, Utilization Management/Case Management, Clinical Documentation, ICD-10 Coding Guidelines and DRG assignment or patient outcomes/quality management, preferred.
We are looking for a candidate with strong communication skills, written and verbal. The ideal candidate needs to be comfortable working independently in a collaborative, shared leadership environment.
IDEAL CANDIDATE SHOULD HAVE WORKED FOR THE FOLLOWING COMPANY(IES): Other heatlhcare organizations comparable in size as either a nurse on a medical or surgical unit, or as a HIM/HIT professional with experience in inpatient coding.
Qualifications
Additional Information
All your information will be kept confidential according to EEO guidelines.