Clinical Documentation Specialist

6 days ago


Albuquerque, New Mexico, United States University of New Mexico - Hospitals Full time
Job Description

The Clinical Documentation Specialist is a critical role at the University of New Mexico Hospitals, responsible for ensuring accurate and complete clinical documentation in patient records. This position plays a vital part in supporting medical staff in documenting patient care, diagnosis, and treatment.

Responsibilities
  • Conduct concurrent reviews of clinical documentation to identify and record principal diagnoses, secondary diagnoses, procedures, and assign working MS-DRGs.
  • Communicate with physicians to obtain/clarify specific principal diagnoses or comorbidities and complications, and request clarification of existing documentation.
  • Codify and report data using abstracting and data entry software tools, performing coding, abstracting, and reporting functions.
  • Collaborate with healthcare teams to ensure accurate and complete documentation, adhering to hospital policies and procedures.
  • Maintain confidentiality of patient records, adhering to HIPAA guidelines.
Requirements

To be successful as a Clinical Documentation Specialist, you will need:

  • A Bachelor's Degree in a relevant field (nursing or related education); equivalent experience may be considered.
  • At least one year of directly related experience in documentation improvement or a similar role.
  • An active RN license in New Mexico or reciprocal agreement; Certification as a Certified Coding Specialist (CCS) is preferred.
Estimated Salary

$65,000 - $85,000 per annum, depending on experience and qualifications.



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