Clinical Documentation Specialist

6 days ago


Buffalo, New York, United States United States Steel Corporation Full time

Job Summary

The Quality Clinical Documentation Specialist will play a critical role in promoting an accurate and meaningful database that clearly demonstrates the resources used in patient care. This position will collaborate extensively with healthcare professionals, coding teams, and quality departments to perform concurrent analytical reviews of clinical documentation and coding data.

Key Responsibilities

  • Facilitate obtaining appropriate clinical documentation for clinical conditions or procedures to support severity of illness, expected risk of mortality, and complexity of care.
  • Improve documentation of all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of patient condition in documentation/coded and quality metrics.
  • Coach/teach leaders using quality improvement methodologies to drive desired outcomes and sustain achievements.
  • Oversee the audit of work activities of healthcare staff to verify conformance to quality assurance standards.
  • Assist in integrating quality and safety initiatives.

Requirements

  • Bachelor of Science or Bachelor of Arts in Nursing or similar field required.
  • 3 years of experience in patient management, acute care, medical/surgical, or ICU/ED as a licensed Registered Nurse required.
  • 1 year of experience in Clinical Documentation Specialist field, coding classifications systems such as ICD-CM, AP-DRG, APR-DRG, MS-DRG preferred.
  • RN license required upon hire.

Working Conditions

  • Full-time position.
  • 75 bi-weekly hours.
  • 8a-4p scheduled work hours.
  • No weekends or holidays required.


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