The Clinical Documentation Specialist RN facilitates accurate documentation for severity of illness and quality in the patient medical record. This involves extensive concurrent record review, interaction with physicians, health information management professionals, and nursing staff. Responsible for improving the overall quality, completeness, and compliance of clinical documentation. Ensures clear, concise, complete, appropriate, and compliant documentation is present in the patient record reflecting the intended assessment, treatment plan, and care objectives or outcomes formulated by the clinical staff such that proper reimbursement for level
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