The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, patient care providers, and Health Information Management coding staff to ensure the clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of the patient care team on documentation guidelines on an ongoing basis. Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served.
Candidates must be a Licensed Registered Nurse, Bachelor’s and/or other Advanced Degrees preferred. 5 years of clinical experience with two years case management coordination preferred.