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Clinical Documentation Specialist

Inside Higher Ed

Reviews physician documentation to identify the most appropriate DRG and clarify documentation when additional diagnoses are supported but not documented in a way that can be used for final ICD coding.

Supports accurate capture of severity of illness, risk of mortality, co-morbidities, complications, and present-on-admission diagnoses.

Works primarily daytime hours, Monday through Friday, with occasional evenings, nights, and holidays as needed by the department.

Requirements & Qualifications

Required education: ADN

Required related experience: 7 years

Required license/certification: Registered Nurse (RN)

Preferred education: Bachelor's degree

Preferred experience: 5 years of nursing experience

Skills and abilities:

  • Ability to manage multiple tasks and projects in a fast-paced, high-intensity environment
  • Knowledge of nursing theory
  • Proficiency in Microsoft Office
  • Strong attention to detail
  • Excellent planning and organizational skills
  • Effective written and verbal communication
  • Ability to solve routine problems and manage resources
  • Strong customer service, time management, and judgment

Physical requirements:

  • Lifting, pushing, and/or pulling objects up to 10 lbs
  • Regular walking or standing with objects up to 10 lbs
  • Regular sitting at a computer workstation for extended periods with repetitive motions
  • Occasional job-related travel

Location

Lexington, Kentucky, US

Employment Type

Full-time

Experience Level

Senior

Salary Range

$54,080 - $95,056

Remote work allowed

No

Posted

1 week ago

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