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Clinical Documentation Specialist Job
Job Number: LCS14021
Job Title: Clinical Documentation Specialist
Department: Clin Documentation Specialists - 0014680
Facility: Corporate Headquarters
Location: Providence, RI
Bachelor degree in nursing; masters preferred, with current licensure to practice as registered nurse in State of Rhode Island or in another state that participates in the Nurse Licensure Compact.
Three to five years registered nurse clinical experience in similarly complex acute care setting.
Familiarity with utilization review, case management, nurse review activities or coding experience preferred. Depending upon need, experience and expertise with a specific patient population may be required. Experience should also demonstrate:
- Knowledge of care delivery documentation systems and related medical record documents.
- Working knowledge of coding structures.
- Ability to work independently in time oriented environment.
- Strong communication skills – both written and verbal.
- Good interpersonal skills, with ability to identify and effectively resolve issues.
Under general supervision of Director Clinical Documentation, provides for concurrent analysis of clinical documentation in medical records to ensure documentation accurately and completely reflects severity of patient illness. Collaborates extensively with physicians, nursing staff, other patient caregivers and health information management coding staff to improve quality and completeness of documentation of care provided and coded. Facilitates concurrent modifications to clinical documentation to ensure clinical severity and services rendered to patients are documented accurately. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Updates and educates all members of patient care team on ongoing basis in regards to documentation issues.