POSITION SUMMARY: The clinical documentation specialist collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction, and submission of accurate data required by CMS. Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a DRG based payer (Medicare, Medicaid). Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates all clinical staff concerning accurate and effective clinical documentation.

MINIMUM QUALIFICATIONS:

EDUCATION: RN; Graduate of accredited school of nursing. BSN preferred.

CERTIFICATION/LICENSES: Licensed as a Registered Nurse in the State of New Mexico.

SKILLS:

• Basic computer skills in word processing and spreadsheet utilization.
• Excellent written and verbal communication skills.
• Proficient in computer use (desktop and/or laptop).
• Demonstrates basic knowledge regarding HIM coding standards.
• Analytic skills necessary to accurately assess patient medical records.
• Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes.
• Ability to be flexible and adjust to workload/assignment changes and interruptions.

EXPERIENCE: Minimum of 5 years recent experience in an acute care setting in a clinical nursing field required. Prior experience in clinical documentation improvement, utilization review/management, discharge planning, quality management, case management or coding preferred.

NATURE OF SUPERVISION:

-Responsible to: Director of Case Management Services

ENVIRONMENT: Bloodborne pathogen: A

General office environment and general hospital department/nursing units.

PHYSICAL REQUIREMENTS: Ability to walk and stand 80% of work time.