Responsible for concurrent review of the clinical documentation in the medical record to facilitate appropriate physician documentation to accurately reflect patient severity of illness, risk of mortality, and DRG assignment; responsible for review and analysis of inpatient medical record documentation requirements per established guidelines. The Clinical Documentation Specialist is responsible for effective communication with physicians and all other staff to achieve complete, accurate and timely documentation as necessary on a daily basis.
RN or LPN (Alabama license required), Certified Clinical Coding Specialist (CCS)
Knowledge of Microsoft word, excel, access and power point preferred.
3 yrs. of clinical nursing experience preferred, clinical documentation specialist experience preferred, coding/DRG knowledge preferred.
BLS/CPR a must.