The Clinical Documentation Specialist supports accurate clinical documentation in the medical record to reflect severity of illness and quality of care. The role involves extensive record review, collaboration with physicians, health information management professionals, and nursing staff, and active participation in team meetings and staff education related to documentation improvement.
Key responsibilities
- Review electronic medical records for completeness and accuracy related to severity of illness and quality
- Identify opportunities for documentation improvement
- Initiate severity worksheets for inpatients
- Prepare clinically credible documentation clarifications
- Communicate documentation clarification requests to physicians for SOI, Core Measures, and Patient Safety
- Follow up on cases and resolve documentation clarification issues
- Coordinate with HIM staff to resolve discrepancies
- Input reconciliation data accurately
- Educate physicians and staff on documentation goals and requirements
- Support documentation strategies, chart audit findings, and quality improvement efforts
- Maintain confidentiality of patient financial and medical record information
- Contribute to accurate, timely patient account management
Requirements & Qualifications
Required qualifications
- Current unrestricted Washington State Registered Nurse license
- Minimum 5 years of recent clinical experience as an RN in an acute care setting or experience in Utilization Review
- Ability to pass a pre-hire clinical exam with a minimum score of 70%
- Effective communication skills with providers
- Knowledge of hospital clinical practice standards and ancillary service departments
- Familiarity with health care audit and research design
- Functional knowledge of DRG coding systems
- Experience with Utilization Review activities and knowledge of JCAHO, PRO, HCFA, and other regulatory bodies
- Knowledge of third-party payer review, reimbursement systems, and utilization monitoring requirements for acute care facilities
- Strong critical thinking, problem-solving, deductive reasoning, organizational, analytical, writing, and interpersonal skills
- Basic computer skills and familiarity with Windows-based software
- Knowledge of the regulatory environment
- Ability to meet productivity guidelines and goal standards
Preferred qualifications
- Bachelor of Science in Nursing
- Understanding of core measures and patient safety indicators
Location
Washington, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$94,894 - $142,341
Remote work allowed
No
Posted
1 week ago