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Clinical Documentation Specialist

2 months ago

Elk Mills, Maryland, United States ChristianaCare Full time
Job Title: RN Clinical Documentation Specialist

We are seeking a skilled Registered Nurse to improve the quality and completeness of clinical documentation within the inpatient medical record.

Job Summary:

The RN Clinical Documentation Specialist will facilitate modifications to clinical documentation through concurrent interaction with physicians and the coding staff to support accurate reimbursement and clinical severity. This role will also educate members of the patient care team on documentation guidelines and serve as a clinical resource for the HIM coding department.

Key Responsibilities:
  • Concurrent review of inpatient medical records to identify potential gaps in physician documentation.
  • Communication with physicians and other providers to validate observations and prompt for documentation as needed.
  • Application of HIMS standards of coding to ongoing evaluation of medical record documentation.
  • Identification of patients appropriate for Hospital Quality Measures and prompting of RN and physician for clinical documentation.
  • Educating physicians and other key healthcare providers on clinical documentation improvement and the need for accurate and complete documentation.
  • Review and clarification of clinical issues in the health record with coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
  • Identification of trends and opportunities to improve clinical documentation and presentation of findings to the clinical documentation initiative team.
  • Attendance at coding and financial educational programs and regulatory updates to maintain proficient knowledge base.
Requirements:
  • Bachelor's degree in nursing.
  • DE RN licensed or RN Compact State License.
  • Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting preferred.
  • RN experience in Cardiac, Critical Care, Med-Surg, and Oncology experience highly desirable.
  • Clinical Documentation, Case Management, Performance Improvement, or Inpatient Coding experience highly desirable.
  • Certified Clinical Documentation Specialist (CCDS) certification required within a year of eligibility.
Benefits:
  • Holiday Pay
  • Guaranteed Hours
  • Continuing Education
  • 403b retirement plan
  • Pet insurance
  • Cancelation protection
  • Wellness and fitness programs
  • Mileage reimbursement
  • Employee assistance programs
  • Medical benefits
  • Dental benefits
  • Vision benefits
  • Benefits start day 1
  • License and certification reimbursement
  • Life insurance
  • Discount program