Clinical Documentation Specialist

Job Summary and Responsibilities

As our Clinical Documentation Specialist, you will facilitate and obtain appropriate physician documentation for clinical conditions or procedures, ensuring accurate severity of illness, expected risk of mortality, and complexity of patient care.

Every day you will educate members of the patient care team (including physicians, allied health practitioners, nursing, and case management) on documentation guidelines and regulatory requirements. You will also support timely, accurate, and complete documentation, working independently with a high degree of autonomy, to ensure robust reporting of hospital and physician-based outcomes.

To be successful in this role, you will possess expertise in clinical documentation improvement, a strong understanding of coding and regulatory requirements, excellent communication and educational skills, and the ability to work autonomously to optimize documentation integrity and support accurate outcome reporting.

• Assists in improving the overall quality and completeness of physician clinical documentation by performing admission and continued stay reviews using clinical documentation improvement strategies and official coding guidelines.
• Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care rendered to patients.
• Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital and physician-based outcomes.
• Educates members of the patient care team including providers, nursing, case management, and other disciplines regarding documentation guidelines and regulatory requirements.
• Demonstrates knowledge of DRGs, hospital quality initiatives, clinical documentation requirements, and regulatory requirements.
• Able to effectively educate providers and other members of the healthcare team on clinical documentation, quality, and coding opportunities.

Job Requirements

Required

• Nursing Diploma or Associate's Degree
• Valid RN license from state of employment or from compact state
• Two (2) years of nursing experience in the inpatient hospital setting (critical care and/or strong med/surg experience preferred) or two (2) years nursing experience in the inpatient hospital setting and one (1) year of CDI experience
• Must demonstrate clinical competency through successfully passing Clinical Competency exam through Nuance
• Must demonstrate CDI software competency through passing CDEOne exam within two (2) months of starting role
• Proficient in use of Electronic Health Record

Preferred

• BSN
• Experience in health information management or hospital quality program
• Clinical Documentation Specialist amd/or Certified Documentation Improvement Practitioner through American Health Management Association

Where You'll Work

With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.