Responsibilities:

The Clinical Documentation Improvement Specialist is a professional nurse accountable for the documentation management of a group of patients. The clinical documentation specialist focuses on safe effective patient care, customer satisfaction and quality outcomes. They are responsible for assisting in maintaining a financially stable department, promoting their own development with an emphasis on evidence based practice and education supported by a Practice Governance framework. Upon admission and concurrently throughout the inpatient stay, the clinical documentation specialist reviews the medical record for documentation that is ambiguous or nonspecific. The clinical documentation specialist proactively engages the physician in discussion to clarify documentation to ensure the inpatient medical record accurately reflects the patient’s severity of illness and the intensity of services provided. The clinical documentation specialist collaborates in the application of Core Measures to manage the care of targeted diagnoses within the system’s primary service lines.

Qualifications:

Required:

Three years in a critical care or medical surgical hospital setting

Bachelor Degree - If education requirement of BSN met, then RN is required. If education requirement of Medical Degree is met, then RN is not required.

Registered Nurse - If education requirement of BSN met, then Registered Nurse (RN) credential is required. If education requirement of Medical Degree is met, then Registered Nurse (RN) credential is not required.

Desired:

One year in case management and/or clinical documentation management.

Bachelor Degree; Doctorate Degree

Certified Clinical Documentation Specialist