CLINICAL DOCUMENTATION SPECIALIS

Direct Staffing Inc; Grand Rapids (MI); On-site; USD 70,000 - 90,000; Full time

Job summary

A leading staffing company is seeking a Clinical Documentation Specialist to enhance medical record quality and ensure compliance. The role involves collaboration with healthcare professionals and the delivery of education on documentation best practices. Candidates should possess a relevant degree and certifications, with strong communication skills emphasized. This position offers an opportunity to contribute to patient care quality in a collaborative environment.

Qualifications

• Current RN license or relevant HIM/HIT certification required.
• 5 years of experience in clinical settings with emphasis on documentation.
• Strong written and verbal communication skills.

Responsibilities

• Improve clinical documentation as an educator and consultant.
• Develop and deliver ongoing education on documentation guidelines and coding.
• Collaborate with medical staff to enhance documentation quality.

Skills

Clinical Documentation

Communication

ICD-10 Coding

Critical Care

Utilization Management

Case Management

Patient Outcomes Management

Education

Bachelor's Degree in Nursing

Health Information Management (HIM)

Associate's Degree in Nursing

Associate's Degree in Health Information Technology (HIT)

Tools

CCDS Certification

RN License

RHIA Certification

RHIT Certification

CCS Certification

Job description

Job Title: Clinical Documentation Specialist

Utilizes advanced knowledge and clinical expertise to improve clinical documentation as an educator and consultant. Assists in enhancing the quality, completeness, and accuracy of medical records. Collaborates extensively with physicians, nursing staff, and other caregivers to ensure appropriate clinical documentation supporting medical necessity and service levels. Develops and delivers ongoing education on documentation guidelines, coding, and reimbursement to the patient care team.

Skills and Certifications

• Bachelor's Degree in Nursing or Health Information Management (HIM) with 5 years of experience
• Associate's Degree in Nursing or HIT with 10 years of experience
• RN, RHIA, RHIT, or CCS certification
• Certified Clinical Documentation Specialist (CCDS) preferred
• Experience in Critical Care, Utilization Management/Case Management, Clinical Documentation, ICD-10

Ideal Candidate

The ideal candidate will have one of the following qualifications:

1. BSN with 5 years experience on a medical or surgical unit
2. Bachelor's degree in HIM with 5 years inpatient coding experience
3. Associates in Nursing with 10 years experience on a medical or surgical unit
4. Associates in HIT with 10 years inpatient coding experience

Current RN license or relevant HIM/HIT certification. CCDS preferred. Experience in Critical Care, Utilization/Case Management, Clinical Documentation, ICD-10 Coding, DRG assignment, or patient outcomes/quality management is a plus.

Strong communication skills, both written and verbal, are essential. The candidate should be comfortable working independently within a collaborative, shared leadership environment.

Additional Information

All information will be kept confidential according to EEO guidelines.

Company: Direct Staffing Inc