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Job Requirements of Clinical Documentation Spec:
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Employment Type:
Full-Time
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Location:
Fort Wayne, IN (Onsite)
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Clinical Documentation Spec
Summary
Summary
Reviews clinical documentation in the medical record to ensure the record accurately reflects the care provided. Asks for clarifications from the medical staff via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of illness and the intensity of service. Serves as the bridge between coding and clinical staff.
Education
Must obtain Bachelor of Science in Nursing (BSN) within three years of employment or will not be eligible to continue in the role. Coursework is completed outside of work hours. Nurses with an Associate of Science in Nursing (ASN), hired/rehired or transferred from a non-nursing position prior to 12/1/17 are grandfathered into the role and not required to obtain BSN.
Licensure/Certification
Must be an RN with current licensure. Clinical Documentation Specialist Certification (CCDS) is encouraged when prerequisites to apply for the exam are met.
Experience
Minimum of three years of clinical experience in an acute care setting and/or three years of clinical coding experience in an acute care setting, including competence with computerized information system.
Other Qualifications
Must have good verbal and written communication skills. Must be available to work flexible hours, assuming on-call duties on weekends and other times when deemed necessary. Must be available to respond within a reasonable length of time.