Compliant Documentation Specialist

1 month ago


Huntington Beach, California, United States Cabell Huntington HospitalSt. Mary Full time
Job Title: Clinical Documentation Improvement Specialist

Cabell Huntington Hospital/St. Mary is seeking a skilled Clinical Documentation Improvement Specialist to join our team. As a key member of our healthcare team, you will play a vital role in ensuring the accuracy and quality of medical records.

Responsibilities:
  • Review medical records to identify areas for improvement and implement changes to ensure accurate representation of patient care.
  • Collaborate with physicians, HIM professionals, and nursing staff to educate and train on clinical documentation best practices.
  • Participate in team meetings and contribute to the development of education programs to promote clinical documentation improvement.
  • Utilize clinical expertise to manage patients in the ICU and CCU settings, with a focus on clinical documentation improvement.
  • Develop and maintain knowledge of Pathophysiology and Disease Process, as well as basic computer skills and familiarity with Windows-based software programs.
  • Support DRG documentation strategies and navigate CDI software products.
Requirements:
  • 2+ years of experience in Adult ICU settings.
  • Registered Nurse licensure in West Virginia or ability to obtain by hire date.
  • Bachelor's Degree with clinical background required.
  • Compliant Documentation Improvement Specialist Certification preferred.
  • 5+ years of position-related experience required.

Candidates must possess excellent organizational, analytical, writing, and interpersonal skills, with the ability to build effective relationships with the healthcare team. Critical thinking, problem-solving, and deductive reasoning skills are essential for success in this role.



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