Job Description


The Clinical Documentation Specialist RN facilitates accurate documentation for severity of illness and quality in the patient medical record. This involves extensive concurrent record review, interaction with physicians, health information management professionals, and nursing staff. Responsible for improving the overall quality, completeness, and compliance of clinical documentation. Ensures clear, concise, complete, appropriate, and compliant documentation is present in the patient record reflecting the intended assessment, treatment plan, and care objectives or outcomes formulated by the clinical staff such that proper reimbursement for level of service rendered is validated and obtained in a timely manner. Active participation in team meetings and education of staff in the Clinical Documentation Management Program (CDMP) process is a key role. The Clinical Documentation Specialist uses critical thinking, problem solving, deductive reasoning, analytical skills, writing and interpersonal skills in a dependable, self-directed and pleasant manner to achieve results while reviewing patient medical records.

Reviews inpatient medical records to identify payer source (Medicare, Blue Cross/Blue Shield) upon admission and throughout hospitalization and effectively communicated differences between Medicare Part A and Part B guidelines and how they impact DRG assignments to medical staff. Utilizes knowledge of Core Measure and Patient Safety Indicators when reviewing and analyzing selected inpatient medical records for all of the following, including but not limited to: chief complaint; presentation; history of present illness; past medical, surgical, and social history; clinical status of patient; diagnostic tests, evaluations, and studies; clinical decision making; and treatment plan, in order to identify potential gaps in clinical documentation; meets established productivity targets for record review as determined by Director. Interacts and directly communicates with attending physicians and medical staff (physicians, physician assistants, and advanced practice nurses), nursing staff, and other patient care providers both verbally or in written form on a concurrent basis to validate observations and suggest additional and /or more specific clinical documentation. Works closely with professional coding staff to assure documentation of discharge diagnosis and any co-existing co-morbid conditions (CC's) are a complete reflection of the patient's clinical status and care by demonstrating basic knowledge about standards of coding and applying ongoing evaluation of inpatient medical record clinical documentation. Recommends and implements, under collaboration and direction of Director and physician leadership, specific tools to support medical record clinical documentation including but not limited to forensic inpatient record assessment, analysis, and review; population of databases for statistical evaluation of same; coordinates future education projects; develops and implements plans for both formal and informal education of medical staff, nursing, and other clinical staff; identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation; facilitates multidisciplinary team in efforts for clinical documentation improvement. Other duties as assigned.

Minimum Requirements:

  • Associates Degree in Nursing
  • Three (3) or more years RN Med Surg Experience


Work Schedule: 8-hours, Days, Monday through Friday


Physical Requirements and working conditions for this position will be provided to you upon interview.


Application Instructions

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