Clin Documentation Spec III

Role Overview:

• Ensures overall quality and completeness of medical record documentation.
• Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, and coding staff.
• Supports timely, accurate documentation for measuring and reporting physician and hospital outcomes.

Qualifications:

• Minimum 5 years of experience as a Clinical Documentation Specialist in an acute setting, preferably Level 1 Trauma Center.
• Must be a Registered Nurse, with BSN or International medical graduate preferred.
• Holds CCDS or CDIP certification, and coding certification such as CCS, CRC, or CIC.

Skills & Requirements:

• Proficient in EPIC EHR, Solventum, and CDI subject matter expertise for all payors and DRG groups.
• Demonstrates excellent critical thinking, problem-solving, and communication skills.
• Proficient in Microsoft Office Suite and typing at 60 WPM.