The Clinical Documentation Specialist is a Registered Professional Nurse responsible and accountable for the review of clinical documentation to assure it meets hospital requirements. Demonstrates knowledge of nursing theory, practice and leadership ability. Plans, organizes, coordinates and evaluates the quality of clinical documentation and works collaboratively with Medical and Hospital staff to assure compliance.

Reviews inpatient medical records for identified payer population (Medicare, Medicaid, Blue Cross/Blue Shield) as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation. Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation. Works closely with HIS coding staff to assure documentation of discharge diagnosis(es) and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care. Demonstrates basic knowledge about HIS standards of coding and applies to ongoing evaluation of medical record documentation. Consistently meets established productivity targets for record review. In collaboration with physician leadership, designs and implements specific tools to support medical record physician documentation. Develops and implements plans for both formal and informal education of physician, nursing and other clinical staff. Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offers solutions and participates in their resolution. Maintains the confidentiality of information acquired pertaining to patient, physicians, associates and visitors to hospital. Discusses patient and hospital information only among appropriate personnel in appropriately private places.

Licensed and currently registered under the laws of the State New York. Minimum of five (5) years experience in adult inpatient medical/surgical or critical care or case management. BSN, MSN preferred degree or national professional certification preferred. Possesses well-developed and effective interpersonal skills and is able to communicate effectively verbally and in writing to influence physician documentation processes. Demonstrates nursing skill competencies and critical thinking. Possesses analytic skills necessary to clinically assess medical records. Demonstrates confidence in actions and exercises good judgment. Demonstrates competency skills in word processing and spread sheets utilization. Displays leadership ability and the willingness to assume authority and accountability for role functions. Possesses the ability to plan, organize, develop and implement goals, objectives, policies and procedures necessary for quality care. Demonstrates ability to recognize problems, approach them in an objective manner, reach appropriate solutions, implement them and evaluate for effectiveness. Embraces and adapts to change. Other related duties as assigned. CDI experience preferred.