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Job Description Summary

The Clinical Documentation Specialist facilitates accurate and compliant medical record documentation in an effort to improve hospital and physician profiles, resulting in correct and optimal DRG assignment for selected diagnostic groups. The Clinical Documentation Specialist serves as a resource to hospital and medical staff for compliance to regulatory standards.

Job Description

QUALIFICATIONS:

• Current licensure as registered nurse in State of Alabama;
• Bachelors Degree in Nursing (required) Masters Degree in nursing, case management, health administration, public health, or business administration (preferred);
• At least five years' acute care experience in role of registered nurse;
• Clinical background that would facilitate assessment and analysis of patient care data.

LANGUAGE/ COMMUNICATION SKILLS:

• Demonstrates ability to communicate and organize thoughts, concepts and ideas verbally and in writing with precise word usage, clear meaning, good presentation, vocabulary, grammar and correct spelling.

SKILLS:

• Demonstrates advanced computer skills (ability to generate reports, graph trends);
• Basic knowledge of data analysis;
• Clinical knowledge and experience in the care of patients with multiple and complex diagnoses, disease processes, and care needs;
• Ability to establish priorities and meet deadlines;
• Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge;
• Ability to develop leadership skills and to serve as a role model for clinical staff;
• Ability to lead and actively participate in multidisciplinary teams;
• Ability to work independently within a team structure and time oriented environment;
• Working knowledge of Medicare reimbursement and coding structures.

Shift

Day

Shift Details

7:00 am - 3:00 pm

FTE

1

Type

Regular

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Equal Employment Employer

Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.