Clinical Documentation Spec - RN

Less than 5 years experience  • 

Salary depends on experience
Posted on 02/23/18
Barrington, IL
Less than 5 years experience
Salary depends on experience
Posted on 02/23/18

The Clinical Documentation Specialist will facilitate the modifications of clinical documentation through extensive initial and concurrent interaction with physicians and other members of the healthcare team, to support appropriate documentation of the clinical severity and risk of mortality is captured for the level of services rendered to select inpatients populations. This role will supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes and provides education to all members of the health care team on an ongoing basis.

· Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements

· Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies. 

· Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement.  

· Demonstrate positive and effective interpersonal relations dealing with all members of the team (ie co-workers, physicians, leadership, etc.). 

· May be exposed to hazardous materials and life threatening diseases

REQUIREDQUALIFICATIONS:

· Graduate from an accredited school of nursing

· Bachelors of Science in Nursing 

· 5 years relevant clinical experience

· Current nursing license in the State of Illinois.

· Certification in clinical documentation improvement preferred.

· Clinical documentation improvement experiencepreferred

· Ability to prioritize work

· Excellent communication skills

· Good problem solving skills

· Critical thinking skills

· Basic Computer skills

· Effective problem-solver with good interpersonal communication skills, verbal and written

· Effective observation, analytical, and critical thinking skills

· May be exposed to hazardous materials and life threatening diseases

· This position needs to recognize needs and behaviors of specific age groups of patients treated

· Ability to work under stressful conditions and in difficult situations

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