Clinical Documentation Improvement Coordintor

King Faisal Specialist Hospital and Research Center; Jeddah; On-site; SAR 150,000 - 200,000; Full time

Job summary

A leading healthcare institution in Jeddah is seeking a professional to oversee the review of medical records for completeness. The role involves engaging with healthcare providers to ensure accurate data recording and improve documentation quality. Applicants should have a Bachelor's or Associate Degree in Nursing or Health Information Management and relevant experience. An educational background in healthcare is essential.

Qualifications

• 4 years of experience with a Bachelor's, or 6 years with an Associate Degree/Diploma in a healthcare-related field.

Responsibilities

• Review inpatient medical records for identifying gaps.
• Provide consistent feedback to healthcare providers.
• Engage in educational sessions for documentation improvement.

Skills

Clinical documentation review

Data consistency

Education and training

Education

Bachelor's or Associate Degree in Nursing or Health Information Management

Job description

Overview

Responsible for reviewing medical records for completeness by monitoring the healthcare providers’ compliance about recording the patient’s medical related data (treatments, medications, requests) to support the accurate assignment of codes.

Responsibilities

1. Provides advanced level review of inpatient medical records to identify gaps in clinical documentation.
2. Ensures consistency of data captured by strictly following existing guidelines and constantly providing timely feedback to healthcare providers.
3. Follows-up with the healthcare providers regarding existing clarifications to obtain needed documentation specification.
4. Engages healthcare providers in ongoing educational sessions in regards to documentation improvement.
5. Reports any gaps, lack of compliance, and findings in the medical records to the responsible Manager or Team Leader.
6. Engages medical staff in the process of reviewing clinical documentations for better awareness and smooth knowledge transfer.
7. Maintains a record of clinical documentation reviews performed and the gaps identified.
8. Performs other related duties as assigned.

Qualifications

• Education: Bachelor’s or Associate Degree/Diploma in Nursing, Health Information Management or other healthcare related discipline is required.
• Experience Required: Four (4) years of related experience with Bachelor’s, or six (6) years with Associate Degree/Diploma is required.