Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist responsible for improving the quality and completeness of clinical documentation in the legal medical record.

Key Responsibilities

• Facilitate necessary documentation in the medical record through interaction with physicians, HIM, and coding staff
• Educate physicians on clinical documentation needs and coding and reimbursement opportunities
• Monitor acute care medical records for accuracy and obtain missing information via queries when necessary

Required Qualifications

• Knowledge of medical terminology and procedures
• Experience with clinical documentation guidelines and policies
• Ability to perform concurrent clinical record reviews
• Understanding of reimbursement processes related to clinical documentation
• Experience in a healthcare setting, preferably with acute care documentation