RN Clinical Documentation Specialist

About This Role

This role involves improving inpatient medical record documentation by interacting with and educating physicians and other licensed independent practitioners. The specialist will review documentation and coding for its impact on potential denials, patient safety indicators, quality, hospital-acquired conditions, and mortality index.

Responsibilities

• Perform inpatient documentation audit and review
• Develop processes to identify opportunities for documentation improvement, intervene with attending physicians, and facilitate improvement in electronic medical record documentation (EPIC)
• Interact with medical staff and others relative to documentation improvement
• Conduct one-on-one teaching for physicians and educate physicians/practitioners regarding documentation and its effects
• Initiate and maintain records and databases to quantify the impact of interventions and ensure follow-through of recommendations
• Identify, investigate, and evaluate practices and processes to facilitate continuous improvement in complete and accurate medical record documentation, including second-level reviews as needed
• Coordinate clinical information from various sources and databases to develop recommendations for documentation
• Educate department personnel from individual expertise and experience
• Demonstrate personal excellence in customer service for both internal and external customers
• Hold staff accountable for the delivery of excellent customer service
• Participate in team efforts to increase the level of customer satisfaction
• Demonstrate the ability to recognize an opportunity for improvement and to collect and assess data
• Demonstrate the ability to develop, implement, and evaluate a Performance Improvement Plan
• Participate in Departmental/Hospital-wide activities which improve processes/outcomes
• Utilize resources to maintain and improve self-knowledge and development and foster the same for employees
• Demonstrate compliance with licensure/certification requirements and the timeliness of their submission
• Collaborate with employees to control costs and pursue additional revenue opportunities
• Complete projects/assignments within projected time frames and expectations

Requirements

• Current CDI experience in conjunction with strong med/surg clinical experience
• Experience working with Quality, HIM, Infection Control, Physicians
• Clear interpersonal and communication skills
• Analytical skills to interpret medical record documentation and departmental metrics
• Self-motivated individual with critical thinking skills
• Ability to work independently with minimal supervision