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The Clinical Documentation Specialist evaluates physician documentation to ensure accurate representation of patient severity of illness for coding purposes. They also provide guidance to physicians, nursing, and ancillary staff regarding clinical documentation best practices.
Summary
Job Description:
Baptist Health is looking for a Clinical Documentation Specialist to join our team. This is a remote position that requires residence in either KY or IN
The Clinical Documentation Specialist is responsible for the evaluation of physician documentation utilizing their clinical expertise to ensure the patients’ severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy. They provide guidance to the physicians, nursing and ancillary staff on clinical documentation best practices. They must be self-motivated and be adaptive to change.
Requirements
· Register Nurse with active Kentucky license
· Bachelor’s degree preferred and 3 years acute health care nursing (including 1 year experience in clinical documentation), OR Associate’s degree in Nursing with 5 years acute health care nursing . (Register Nurse with active Kentucky license)
· ACDIS Credential (CCDS) or Certified Documentation Improvement Professions (CDIP) strongly encouraged
· Knowledge of medical record organization
· Knowledge of medical terminology
· Ability to complete assignments in a timely manner despite fluctuations in workflow
· Strong interpersonal, communication and listening skills is required
· Knowledge of e-mail, Word, Excel, data entry and data retrieval systems, Encoder and internet
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