Clinical Documentation Spec, Marshall Medical Centers North, Full-time, Days

Overview

The following statements reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements, which may be inherent in the position.

 

A Documentation Improvement Specialist is responsible for coordination of the review of concurrent inpatient clinical documentation.  The Documentation Specialist works with providers to ensure that clinical disease processes are accurately documented and that the documentation appropriately reflects the patient's severity of illness.

The Documentation Improvement Specialist functions under the direct authority and supervision of the Director of Health Information Management.

Some of the many skills performed

·        Daily management of concurrent documentation improvement functions

·        Coordination of concurrent coding clarification issues with physicians

·        Timely reporting of concurrent coding/documentation improvement efforts

 

Qualifications

EDUCATION

 

·        Associate degree or other two year college equivalent

·        Graduate from an accredited Health Information Technician (HIT) program, Health Information Management (HIM) program or RN education program, BSN preferred

                      

 

LICENSURE/CERTIFICATION:

• Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) with a minimum of 2 years experience in supervision or management with 1 - 3 years of coding experience
• Registered Nurse license with a minimum of five (5) years nursing experience in med/surg, critical care, or emergency services