Clinical Documentation Improvement Specialist, 8A-4:30P

Responsibilities
The Clinical Documentation specialist is a professional nurse accountable for the documentation management of a group of patients. 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. Throughout the Care Continuum, the Clinical Documentation specialist reviews the medical record for documentation that is ambiguous or non-specific. The Clinical Documentation specialist proactively engages the physician in discussion to clarify documentation to ensure the medical record accurately reflects the patients severity of illness, intensity of services provided.
Qualifications
Required:

• Three years in a physician practice setting and/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 (KY) - 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. Knowledge of physician practice coding rules and guidelines.
• Bachelor Degree Nursing
• Doctorate Degree Medicine
• Certified Clinical Documentation Specialist