CLINICAL DOCUMENTATION SPECIALIST

Direct Staffing Inc; Birmingham (AL); On-site; USD 60,000 - 80,000; Full time

Job summary

A healthcare staffing agency is seeking an RN Clinical Documentation Specialist to conduct reviews of inpatient medical records and evaluate clinical documentation. The role requires building a collaborative environment with medical staff and ensuring accurate physician documentation. Candidates should have previous clinical documentation experience and a background in a Hospital Acute Care setting. The position demands a self-motivated individual who can work independently while demonstrating excellent initiative.

Qualifications

• Previous Clinical Documentation Experience is highly desired.
• Case management experience is helpful.
• Candidate must have worked in a Hospital Acute Care environment.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews.
• Evaluate the clinical documentation of acute care services.
• Work closely with physicians and medical staff for documentation.

Skills

Nursing

Clinical Documentation

Electronic Clinical Information Systems

Education

Associate's Degree in Nursing

Bachelor's or Master's in Nursing Preferred

Job description

The RN Clinical Documentation Specialist conducts clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation of acute care services. He/she works with minimum supervision and must be self‑motivated and demonstrates excellent initiative. This individual works closely with physicians and medical staff to facilitate appropriate physician documentation of patient care. He or she will play a key role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services. Previous CDI experience is highly desired. Case management experience is helpful. The selected candidate will be able to build a collaborative work environment with physicians, physician extenders, nurses, case managers and medical records coders.

Skills and Certifications

• Associate's Degree in Nursing; Bachelor's or Master's in Nursing Preferred
• Competency in electronic clinical information systems

Ideal Candidate

The ideal candidate will be a Registered Nurse with previous Clinical Documentation Experience.

Ideal Candidate Should Have Worked In

Candidate must have worked in a Hospital Acute Care environment.

Additional Information

All your information will be kept confidential according to EEO guidelines.

Direct Staffing Inc

Job Location