Clinical Documentation Specialist
Summary
Reviews inpatient medical records to ensure accurate documentation of care, severity of illness, and reimbursement compliance for a healthcare provider.
The Clinical Documentation Specialist provides clinically based concurrent and retrospective review of inpatient Medicare medical records to evaluate the utilization and documentation of acute care services, which includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Plays a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.
Minimum Education: Must possess a current, valid RN license and relevant education.
Minimum Experience: Three years clinical experience acute setting.
Required Licensure: Registered nurse, Licensed Masters Social Worker
FLSA Status: Exempt
Salary Grade:
Skills:
** Note – Required certifications are to be completed by 3 months of employment.
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