Clinical Documentation Specialist: Elevate Care Records

Concord Hospital; Concord (NH); On-site; USD 70,000 - 95,000; Full time

Job summary

Concord Hospital in Concord, NH seeks a Clinical Documentation Specialist to enhance the quality and compliance of medical record documentation. You will review records, query physicians, and educate care teams on accurate documentation to support hospital resources and patient acuity.

The role requires four years of related experience, RN or equivalent, and CCDS/CDIS certification as applicable. This full-time position emphasizes independent work and collaboration.

Qualifications

• Four years of formal training or education beyond high school (e.g., Bachelor’s Degree).
• RN preferred; CDIS/CCDS credential required or obtained soon after hire.

Responsibilities

• Work product impacts the productivity and quality goals for clinical documentation improvement program.
• Demonstrates knowledge of MS-DRG's/APR-DRGs documentation requirements and guidelines.
• Obtains needed clarification of clinical documentation to ensure documentation is complete and accurate.
• Identifies trends in documentation opportunities and provides education to appropriate audience to ensure compliance with documentation and coding guidelines.
• Reports ongoing issues and improvement plans.
• Utilizes the software system to track and analyze outcomes of documentation improvement efforts.
• Assists to develop and maintain clinical documentation improvement policies and procedures.
• Attends CDIP meetings and educational sessions and discusses trends and findings.

Skills

Attention to detail

Communication

Time management

Education

Bachelor’s Degree

RN preferred

CDIS/CCDS certification

Tools

CDR2/Claro

Job description

Concord Hospital in Concord, NH seeks a Clinical Documentation Specialist to enhance the quality and compliance of medical record documentation. You will review records, query physicians, and educate care teams on accurate documentation to support hospital resources and patient acuity.

The role requires four years of related experience, RN or equivalent, and CCDS/CDIS certification as applicable. This full-time position emphasizes independent work and collaboration.