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RN Clinical Documentation Specialist
2 months ago
We are seeking a skilled RN Clinical Documentation Specialist to join our team at Christiana Care Hospital in Newark, DE. As a key member of our clinical documentation team, you will play a critical role in improving the overall quality and completeness of clinical documentation within the inpatient medical record.
Key Responsibilities:- Concurrently review inpatient medical records to identify potential gaps in physician documentation and communicate with physicians or other providers to validate observations and prompt for documentation as needed.
- Analyze clinical status of patients, current treatment, and past medical history to identify areas for improvement in clinical documentation.
- Apply knowledge of HIMS standards of coding to ongoing evaluation of medical record documentation and identify patients appropriate for Hospital Quality Measures.
- Educate physicians and other healthcare providers on clinical documentation improvement and the need for accurate and complete documentation in the health record.
- Review and clarify clinical issues in the health record with coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
- Identify trends and opportunities to improve clinical documentation and present potential solutions to the clinical documentation initiative team.
- 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.
This is a hybrid position with remote and onsite requirements. The successful candidate will work in a nursing unit environment with no patient contact and will be required to work in a normal office environment with frequent deadline situations.
