Clinical Documentation Specialist

4 weeks ago


Attleboro, Massachusetts, United States Sturdy Memorial Hospital Full time
Clinical Documentation Specialist Job Description

We are seeking a highly skilled Clinical Documentation Specialist to join our team at Sturdy Memorial Hospital. As a Clinical Documentation Specialist, you will play a critical role in ensuring the accuracy and completeness of patient medical records.

Key Responsibilities:
  • Conduct concurrent review of clinical documentation in medical records to identify missing or understated diagnoses.
  • Review medical records with a clinical lens to identify areas for improvement and ensure compliance with regulatory requirements.
  • Collaborate with medical staff to obtain accurate and complete physician documentation that supports patient condition(s) and treatment plan.
  • Perform thorough chart reviews to determine principal and secondary diagnoses for quality rating purposes.
  • Coordinate with coding, HIM, and UR departments to achieve accurate and complete medical records.
Requirements:
  • Bachelor's degree in a related field (e.g., nursing, healthcare administration).
  • Current RN license.
  • Extensive clinical knowledge and understanding of pathology and physiology.
  • Strong critical thinking skills and ability to review medical records to identify information not yet documented.
  • Excellent written and verbal communication skills.
  • Assertive personality traits to facilitate ongoing physician communication.
  • Working knowledge of inpatient admission criteria.
  • Ability to work independently in a time-oriented environment.
Preferred Qualifications:
  • Inpatient bedside nursing experience.
  • Case Management or Utilization Review experience.
  • Open to RNs with previous CDI experience (CCDS preferred).
Sturdy Memorial Hospital is an equal employment opportunity employer. We are committed to diversity and inclusion in the workplace.
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