The Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation on a concurrent basis through daily review of records and interaction with physicians, health information staff, corporate coders, case managers and other clinical staff.
The qualified individual is responsible for coaching and educating physicians and other clinical staff to improve capture of clinical severity and clinical details based upon services and care rendered to all patients. The individual tracks and analyzes trends, identifies improvement opportunities, and participates in teams focused on improving documentation for long term acute care hospital documentation.
Must have credentials as Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), RHIA, RHIT, RN with Certified Coding Specialist (CCS) credentials or other clinician with five years recent hospital experience and at least 2 years ICD-10 coding and DRG experience. Requires excellent verbal and written communication skills and critical thinking; ability to work independently with deadlines.
Select Medical is an EOE.