Job Abstract

General Summary:

The clinical documentation specialist is responsible for performing concurrent and/or retrospective review of the medical record. Ensures appropriate clinical documentation through engaging the physicians, nursing staff, ancillary departments, and coding staff in a collaborative manner in order to ensure appropriate and accurate reimbursement based on severity of illness, risk of mortality and level of services provided to patients. Provides education and support to all members of the healthcare team regarding clinical documentation including physicians, advanced practice practitioners, nursing staff and ancillary departments. Demonstrates understanding, creativity, enthusiasm, and flexibility while performing in this role in order to meet and support program goals.

Minimum Knowledge, Skills, & Abilities Required:

• Bachelor’s degree in nursing or other healthcare related field, required.
• If a nursing candidate, Registered nurse from an accredited school of nursing or healthcare professional from an accredited school required with an active Maryland License or Compact State.
• Two years of CDS experience preferred; Utilization review experience considered.
• Three to five-years clinical experience in an acute care setting, preferable in medical/surgical, emergency medicine, perioperative, or critical care.
• Previous experience or working knowledge with ICD-10-CM/PC strongly preferred.
• Knowledge of the Maryland GBR and revenue cycle strongly preferred.
• Exhibits effective interpersonal and communication skills.
• Demonstrates a high level of tact, diplomacy, and negotiation skills.
• Demonstrates the ability to apply critical and creative thinking skills.
• Demonstrates the ability to prioritize assignments.
• Employs effective time management skills and techniques.
• Possess knowledge of medical terminology and practices.