Clinical Documentation Specialist RN

This position is responsible for concurrent review of inpatient medical records in order to identify opportunities for improving the quality of physician documentation. This position facilitates modifications to clinical documentation through concurrent interaction with physicians (face-to-face and electronically) and other members of the health care team. The goal of this position is to achieve a complete medical record in order to support complete, accurate and timely coding. The Clinical Documentation Specialist RN communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation. Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team. Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends. They also research literature and stays abreast of CMS rules and regulations. Assists in the development and reporting of performance measures to the medical staff and other departments and prepares physician specific data information. Coaches physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness.