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Clinical Documentation Specialist RN
2 months ago
Job Summary:
The Clinical Documentation Specialist Registered Nurse plays a pivotal role in conducting critical, high-risk and intricate secondary case reviews that are essential for accurate clinical documentation. This ensures that the severity of illness, expected risk of mortality, and complexity of patient care are properly reflected in provider documentation. By enhancing documentation accuracy, the nurse not only supports optimal patient outcomes but also contributes significantly to hospital initiatives such as reducing Length of Stay (LOS) and improving Case Mix Index (CMI). This collaborative effort with Clinical Documentation Improvement (CDI) specialists, coders, providers, and other healthcare team members ensures that documentation aligns with organizational standards, enhancing continuity of care and overall patient safety while meeting regulatory compliance requirements.
Key Responsibilities:
Work Experience:
Three years of direct patient care in a hospital setting is required.
Three years of experience working with inpatient clinical documentation, mortality, PSI, HAC, or other quality-focused reviews is required.
Education and Training:
A Bachelor's Degree in Nursing is required; a Master's degree is preferred.
Skills:
- Extensive clinical knowledge, critical-thinking skills, and understanding of disease processes, pathophysiology, and disease management/treatment.
- Knowledge of risk-adjustment methodologies highly preferred.
- Proficiency with CDI software, CERNER, and encoder. Experience with 3M 360 Encompass is preferred.
- General knowledge of office procedures and operations.
- Skill in data entry with minimal errors.
- Ability to accurately prepare and maintain records, files, reports, and correspondence.
- Ability to communicate effectively in both oral and written form.
- Ability to handle difficult and stressful situations with professional composure.
- Ability to maintain effective interpersonal relationships.
- Ability to understand and follow instructions.
- Proficiency with ICD-10-CM/PCS, APR DRG, and MS DRG is required.
Preferred Qualifications:
CCDS or CDIP certification is preferred. Coding certification (CCS, CIC, or CPC) is preferred.
