Clinical Documentation Specialist

Direct Staffing Inc; Concord (NH); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Pension Plan

Paid time off

Tuition Reimbursement

Free on site fitness center

Job summary

A staffing and recruitment company is seeking a Clinical Documentation Specialist in Concord, NH. The role involves improving the quality and compliance of clinical documentation within the medical record through review and collaboration with healthcare providers. A Bachelor's Degree and certifications in CCS and RN are required alongside 4 years of experience. The position offers a full-time schedule with comprehensive benefits including health, dental, and a pension plan.

Qualifications

• Minimum of 4 years experience in clinical documentation.
• Ability to manage program operations effectively.
• Knowledge of DRG documentation requirements.

Responsibilities

• Facilitate improvement in quality and compliance of clinical documentation.
• Conduct extensive medical record reviews.
• Educate patient care team on documentation standards.

Skills

Clinical documentation expertise

Communication skills

Interpersonal skills

Regulatory compliance

Education

Bachelors Degree

Certified Coding Specialist (CCS)

Professional Registered Nurse (RN)

Job description

Unit Description: The Clinical Documentation Specialist (CDS) has a broad clinical knowledge base and understanding of DRG documentation requirements. The primary purpose of the CDS is to facilitate the improvement in the overall quality, completeness and compliance of clinical documentation in the medical record. The CDS facilitates clarification of clinical documentation through extensive medical record review, interaction with physicians, nursing staff and other caregivers utilizing coding and clinical documentation expertise. The CDS will manage a concurrent query process to accurately capture the appropriate documentation. The CDS is also responsible for educating all members of the patient care team on appropriate documentation to support the use of hospital resources and the acuity of patients served.

Education: Four years of formal training or education in specialty or related specialty beyond the high school level (e.g., Bachelors Degree). Certified Coding Specialist (CCS) required and Professional Registered Nurse (RN).

Experience: 4 years experience in field. Demonstrated ability to effectively manage program operations.

The salary is based on experience. Full benefits including Health, Dental, Pension Plan, Paid time off, Tuition Reimbursement, Free on site fitness center.

On Call requirements: No Call

Certification requirements: CCS - Certified Coding Specialist

Assignment Duration: Perm

Number of Positions Available: 1

Shift: Monday - Friday - Days - Full time

State License: NH

Additional Information

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