RN Clinical Documentation Specialist- Medical Records

Huntsville Hospital; Huntsville (AL); On-site; USD 60,000 - 80,000; Full time

Job summary

A leading hospital in Alabama is seeking a qualified candidate for the role of Clinical Documentation Improvement Specialist. This position focuses on enhancing the quality and accuracy of medical record documentation. The successful candidate will collaborate with healthcare professionals and is expected to have substantial nursing experience, including critical and medical/surgical care. Candidates should also possess a current nursing license and may benefit from additional certifications.

Qualifications

• At least 3-7 years of experience in an acute care hospital setting preferred.
• Current Alabama Nursing License required; CCDS Certification preferred.
• 1 year of CDI experience preferred, or willingness to learn.

Responsibilities

• Facilitate improvement in quality of medical record documentation.
• Ensure completeness and accuracy of clinical information for outcomes profiling.
• Maintain ongoing education related to CDI/ACDIS/AHIMA standards.

Skills

Medical/Surgical Nursing Experience

Critical Care Nursing Experience

Time Management

Critical Thinking

Education

Graduate of an accredited school of nursing

Associates Degree in Nursing or BSN, MSN

Tools

Word

Excel

Job description

Overview

Responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. Obtain appropriate clinical documentation through extensive interaction with physicians, nursing, patient caregivers, and coders. To ensure that appropriate patient centered clinical data, quality metrics and reimbursement is received for the level of services rendered. That the clinical information utilized in profiling and reporting outcomes is complete and accurate. On a consistent basis the individual will maintain ongoing education relative to CDI/ACDIS/AHIMA and the Coding Clinic.

Qualifications

Education required: Graduate of an accredited school of nursing

Education preferred: Associates Degree in Nursing or BSN, MSN

License, Certification and/or Registration: Current Alabama Nursing License. CCDS Certification Preferred or will obtain post 2-3years.

Experience: Prefer at least 3-7 years of experience in an acute care hospital setting. Prefer at least 1 year of CDI experience, if no prior CDI experience, applicant will be educated to current standards

Additional Skills/Abilities:

• Medical/Surgical Nursing Experience
• Critical Care Nursing Experience
• Word and Excel experience preferred
• Time Management skills
• Self-Motivated
• Critical Thinking