Clinical Documentation Specialist

Job Title: Clinical Documentation Specialist

Department Name: Clinical Documentation Integrity

Reports to (Title): Operations Manager



JOB SUMMARY

Clinical Documentation Specialist is responsible to oversee the facility's medical recordkeeping practices. In this role, Clinical Documentation Specialist is responsible for ensuring that clinical documentation complies with federal laws, provide feedback in medical recordkeeping practices, and analyzing medical information.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Applying knowledge of medical terminology and procedures to evaluate clinical documents.

2. Collecting medical information from healthcare providers and updating medical records.

3. Verifying the accuracy of patient medical information and obtaining missing information.

4. Monitoring diagnoses, treatments, and follow-up entries in medical records.

5. Interpreting and preparing clinical reports for healthcare professionals and public health officials.

6. Ensuring that the content and storage of medical documents comply with federal laws.

7. Keeping abreast of advancements in the field of clinical documentation and changes in regulations.

8. Keeping updated to official coding guidelines for diagnosis and be able to follow the facility specific guidelines and instructions.

9. Maintains confidentiality of patient records at all times.

10. Observes HIPAA compliance.

11. Perform as a team player.

12. Use logic, critical thinking and reasoning to identify the strengths and weaknesses of alternative solutions to problems.

13. Understand the effects of new information for both current and future problem-solving and decision-making.

14. High attention to detail

15. Attendance in accordance with company HR and department policies

16. Other tasks/functions that may be assigned by the company as per business requirement; these may change from time to time to reflect the changing requirement of your position and our business.

Education or equivalency:

1. Bachelor of Science in Nursing graduate

2. Licensed Registered Nurse

3. Preferably with work experience in

a. Revenue Cycle (medical coding) experience.

b. Knowledge of medical terminologies, ICD-10 diagnosis coding guidelines, procedures.

c. Clinical or Hospital setting

Certification or Licensure:

• Certification is dependent on client requirement.
  • AAPC Coding Certification: CPC, COC, CIC
  • AHIMA Coding Certification: CCA, CCS-P, CCS

Working Conditions and Physical Requirements:

1. Pleasant work environment.

2. Job requires sitting and working at a computer for extended period of time; 8 hours

minimum.