Clinical Documentation Improvement Specialist

Santa Barbara Cottage Hospital; United States; On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Comprehensive benefits

Wellness programs

Schedule flexibility

Job summary

A leading healthcare institution seeks a Clinical Documentation Specialist to ensure accurate clinical documentation and improve patient outcomes. The role requires collaboration with healthcare professionals and demands 5 years of hospital experience, preferably in critical care settings. Candidates should possess an Associate’s degree and hold relevant certifications, including RN licensure or coding credentials. This position offers valuable contributions to healthcare quality in a supportive environment.

Qualifications

• 5 years of recent hospital experience, preferably in ICU, CCU or complex Med/Surg.
• Previous clinical documentation improvement experience preferred.
• Must hold one of the relevant certifications upon hire.

Responsibilities

• Review clinical documentation for accuracy and quality.
• Educate patient care team on documentation guidelines.
• Collaborate with HIM/Coding professionals.

Skills

Clinical documentation improvement

Communication with healthcare professionals

Collaboration with Coding professionals

Education

Associate’s Degree in nursing or related field

Bachelor’s Degree

Tools

Epic

Job description

Overview

Experience the advantages of real career change. Join Piedmont to move your career in the right direction. Stay for the diverse teams you’ll love, a shared purpose, and schedule flexibility that frees you to live for what matters both in and outside of work. You’ll feel valued, motivated to be your best, and recognized for your contributions to exceptional patient outcomes. Piedmont leaders are in your corner, invested in your success. Our wellness programs and comprehensive total benefits and rewards meet your needs today and help you plan for the future.

Responsibilities

Reviewing clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician\'s clinical documentation. This work involves extensive record review and interaction with physicians, HIM/Coding professionals, nursing staff, and case management. Through collaboration with Coding professionals, educates the patient care team on changes in documentation guidelines and/or documentation deficiencies noted. The patient care team includes but is not limited to: attending physicians, consultants, physician extenders, allied health practitioners, nursing, and case management. The Specialist reports to the Clinical Documentation Improvement Director.

Qualifications

Education

• Associate’s Degree in nursing, Health Information Management or a related field Required
• Bachelor’s Degree Bachelor’s degree Preferred

Work Experience

• 5 years of recent hospital experience/practice, preferably in an ICU, CCU or complex Med/Surg environment Required
• Previous clinical documentation improvement experience, utilization management, precertification, coding, Medicare regulations, quality assurance, or related area Preferred
• Prior experience with Epic Preferred

Licenses and Certifications

• Must have one of the following: Upon Hire Required
• RN - Registered Nurse - Georgia State Licensure and/or NLC/eNCL Multistate Licensure Required or
• CCS-Certified Coding Specialist Required or
• RHIT - Registered Health Information Technician Required or
• RHIA - Registered Health Information Administrator Required or
• CCDS - Certified Cardiac Device Specialist Required

Business Unit

Piedmont Healthcare Corporate