Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.

Reports to: HIMS Director

Minimum Education
Associate’s degree Preferred
Graduate of a Program in Discipline Preferred
Bachelor's degree preferred

Required Skills
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

Required Skills
Certifications:
CCDS or CDIP preferred
Prefer Coders must have CS or CIC

Required Skills
Licenses:
Licensed Registered Nurse (RN), RHIA, RHIT, CCS, Licensed Practical Nurse (LPN), or combination thereof.