Clinical Documentation Specialist **Remote Position

The Clinical Documentation Specialist will be responsible for the day to day management of the Clinical Documentation Improvement Program. The goal is to improve the overall quality and completeness of clinical documentation in the medical record in accordance with all regulatory requirements. This will better reflect the patient's severity of illness and intensity of care. He/she will utilize coding and clinical expertise to identify opportunities to capture complications and co-morbidities during the patients stay. The documentation specialist will obtain appropriate clinical documentation through extensive interactions (clarifications, face to face communication and other tools and programs) with physicians, case managers, nursing staff, and other health care professionals.

Education
Graduate of an approved school of nursing. BSN preferred.

Licensure/Certification
RN Licensure in Georgia required. Obtain Certified Clinical Documentation Specialist (CCDS) credential within three years of hire.

Experience
Minimum of five years nursing experience in an acute care hospital with proven leadership training skills, with some experience in coding/auditing and DRG methodology. CDS, case management, performance improvement, utilization review experience is preferred.

Note: As of 10/2009, current incumbents functioning successfully will be grandfathered with current education and experience levels.

Knowledge, Skills and Abilities
Extensive knowledge of medical record documentation requirements mandated by state/federal regulations, NIAHO standards, and medical staff Rules and Regulations.

Working knowledge of ICD-10-CM coding and DRG reimbursement system.

Excellent written and oral communication skills are necessary to interact with physicians and other clinical and administrative staff.

Strong analytical skills required to review documentation for completeness, identify clinical signs and symptoms, formulate clinical clarifications, and apply coding guidelines.

Ability to work both as a team player and independently.

Experience with personal computers and software applications to work efficiently and key or research data.

Ability to assess, evaluate and teach physicians and other healthcare professionals.

Capable of critical thinking, reasoning, dedication, and inference while displaying the ability to draw accurate conclusions.

Needs excellent organization skills and ability to balance multiple priorities.

Excellent interpersonal skills to gain cooperation and support for the program.

Physical Demands
Visual ability to read documents and view computer screens for extended periods of time. Manual dexterity to use a PC and software packages, pens, pencils, etc. Ability to move about the organization, walking and standing for extended periods of time. Ability to push portable computer carts from one patient care unit to another.