Registered Nurse Clinical Documentation Specialist

POSITION PURPOSE

• Performs concurrent clinical documentation review to promote complete capture of documentation needed to accurately code level of clinical service and patient acuity. Works collaboratively with physicians and coders.

MINIMUM EDUCATION REQUIRED

• Associate Degree in Nursing

MINIMUM EXPERIENCE REQUIRED

• 3 - 5 Years

LICENSES / CERTIFICATIONS REQUIRED

• Licensure to be eligible to practice as a Registered Nurse.

• CCS (Certified Coding Specialist) preferred.

KNOWLEDGE, SKILLS & ABILITIES REQUIRED

• Ability to read, write, hear, speak, and comprehend the English language.

• Strong understanding of pathophysiology, disease processes, and diagnostic testing results.

• General understanding of ICD coding conventions and DRG methodology.

• Strong MS Word and Excel skills.

• Strong organizational, analytical, communication, and interpersonal skills.

• Ability to work independently as well as part of a team.

• Previous acute care clinical experience preferred.

PRINCIPLE ACCOUNTABILITIES AND ESSENTIAL DUTIES

• Performs concurrent medical record review of defined bedded patients, documents provisional DRG, and documents potential working DRGs up until patient discharge.

• Facilitates necessary clinical documentation in the medical record through verbal and written communication with clinicians.

• Evaluates clinical documentation patterns to identify areas for improvement, identifies changes which will proactively collect required documentation, and develops reports to monitor program success and opportunities for concentrated focus.

• Educates patient care team members regarding clinical documentation requirements and coding guidelines and provides feedback on patient care team members’ clinical documentation.

• Works collaboratively with other disciplines to achieve the most precise and reflective final coding.