Clinical Documentation Specialist II

Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement of clinical documentation through the roles of educator and consultant. Facilitates improvement in the overall quality completeness and accuracy of medical record documentation through extensive record review.

Through extensive interaction with physicians and other members of the healthcare team achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.

What the Clinical Documentation Specialist II will do:

• Demonstrates understanding of and facilitates appropriate clinical documentation to ensure that the severity of illness risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality timeliness and completeness of the quality health record to ensure appropriate data provider communication and quality outcomes. Serves as a resource for appropriate clinical documentation.

• Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider participation. Identifies learning opportunities for healthcare providers.

• Conducts concurrent reviews of selected patient health records to address legibility clarity completeness consistency and precision of clinical documentation.

• Collaborates with coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patients clinical status and care. Resolves all discrepancies in a courteous manner.

Minimum qualifications:

• Must possess a comprehensive knowledge of acute care nursing experience as normally obtained through a Bachelor of Science Nursing (BSN) and five (5) years on a medical or surgical unit or Bachelor of Science in Health Information Management (HIM) and five (5) years HIM/inpatient coding experience or an Associate/Diploma Degree in Nursing and ten (10) years on a medical or surgical unit or an Associate Degree in Health Information Technology or in a related healthcare field. Ten (10) years experience in acute inpatient coding preferred

• Current Registered Nurse License in the State of practice Registered Health Information Administrator (RHIA) Registered Health Information Technologist (RHIT) or Certified Coding Specialist (CCS). Certified Clinical Documentation Specialist (CCDS) preferred.

• Experience in Critical Care Utilization Management/Case Management Clinical Documentation ICD-9 Coding Guidelines and DRG assignment or patient outcomes/quality management preferred.

Our Commitment

Rooted in our Mission and Core Values we honor the dignity of every person and recognize the unique perspectives experiences and talents each colleague brings. By finding common ground and embracing our differences we grow stronger together and deliver more compassionate person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability veteran status or any other status protected by federal state or local law.