RN Clinical Documentation Specialist

Overview

Responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. Obtain appropriate clinical documentation through extensive interaction with physicians, nursing, patient caregivers, and coders. To ensure that appropriate patient centered clinical data, quality metrics and reimbursement is received for the level of services rendered. That the clinical information utilized in profiling and reporting outcomes is complete and accurate. On a consistent basis the individual will maintain ongoing education relative to CDI/ACDIS/AHIMA and the Coding Clinic.

Qualifications

Education required: Graduate of an accredited school of nursing

Education preferred: Associates Degree in Nursing or BSN, MSN

License, Certification and/or Registration: Current Alabama Nursing License. CCDS Certification Preferred or will obtain post 2-3years.

Experience: Prefer at least 3-7 years of experience in an acute care hospital setting. Prefer at least 1 year of CDI experience, if no prior CDI experience, applicant will be educated to current standards

Additional Skills/Abilities:

• Medical/Surgical Nursing Experience
• Critical Care Nursing Experience
• Word and Excel experience preferred
• Time Management skills
• Self-Motivated
• Critical Thinking