Clinical Documentation Specialist Inpatient
Birmingham-AL-35201-United States
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Job Summary
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To provide clinically based concurrent review of inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnoses and procedures. The goal of concurrent and retrospective review is to facilitate clinically appropriate physician/ clinician documentation of all patient conditions, treatments, and interventions to accurately reflect quality of care, severity of illness and risk of mortality and risk adjustment factor to support correct coding, reimbursement, and quality initiatives.
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Education
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Associates degree required, BSN preferred
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Experience
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Five years of nursing experience required (3 of these years must be in acute or intensive care setting), prefer pediatric experience. Will consider CDE experience in lieu of pediatric experience. CCDS and/or coding certification highly desired or willingness to complete after employment. Prefer experience with SCM electronic medical record and Soarian Financials.
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Licensures, Certifications, and/or Registries
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Current RN license. CCDS and/or coding certification highly desired or willingness to complete after employment.
PI274133836
