RN Clinical Documentation Specialist

About This Role

This role is responsible for improving the overall quality and completeness of medical record documentation. It involves extensive interaction with physicians, nursing staff, patient caregivers, and coders to ensure accurate clinical documentation. The specialist ensures that appropriate patient-centered clinical data, quality metrics, and reimbursement are received for the services rendered, and that clinical information used for profiling and reporting outcomes is complete and accurate.

Responsibilities

• Facilitate the improvement in the overall quality and completeness of medical record documentation
• Obtain appropriate clinical documentation through extensive interaction with physicians, nursing, patient caregivers, and coders
• Ensure that appropriate patient-centered clinical data, quality metrics, and reimbursement are received for the level of services rendered
• Ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate
• Maintain ongoing education relative to CDI/ACDIS/AHIMA and the Coding Clinic

Requirements

• Graduate of an accredited school of nursing
• Current Alabama Nursing License
• At least 3-7 years of experience in an acute care hospital setting
• Medical/Surgical Nursing Experience
• Critical Care Nursing Experience
• Time Management skills
• Self-Motivated
• Critical Thinking

Nice to have:

• Associates Degree in Nursing or BSN, MSN
• CCDS Certification or will obtain post 2-3 years
• At least 1 year of CDI experience; if no prior CDI experience, applicant will be educated to current standards
• Word and Excel experience