Clinical Documentation Specialist- MD/RN/ NP (In-Person)

About the position

The Clinical Documentation Specialist plays a crucial role in the Clinical Documentation Improvement Department (CDI) at DHR Health. This position is responsible for ensuring that patient care and treatments are accurately documented in medical records, which supports proper coding and DRG assignment. The specialist will work closely with the Director of CDI, other clinical documentation specialists, and medical coding staff to educate healthcare providers on the importance of complete and clear documentation.

Responsibilities

• Oversee the medical record documentation to ensure care and treatments are accurately recorded.
• Educate physicians, clinicians, and other stakeholders on the necessity of complete documentation.
• Support accurate DRG assignment through proper documentation practices.
• Collaborate with the CDI team and coding staff to enhance documentation quality.
• Review clinical documentation for compliance and accuracy.

Requirements

• Medical graduate (M.D) or Doctor of Osteopathy (D.O), Registered Nurse (R.N), or Nurse Practitioner (NP).
• CCS and/or CCA Exam certification within 1 year of employment or CCDS Exam certification within 1 year of employment.
• Minimum 1 year clinical experience in an acute care setting.
• Knowledge of EMR systems and related medical record documents.
• Strong understanding of anatomy, pathology, pharmacology, and physiology.

Nice-to-haves

• Utilization review experience (1 year preferred).
• CCDS certification (preferred).
• RN license (preferred).

Benefits

• Health insurance
• Dental insurance
• Vision insurance
• Life insurance
• Employee discount
• 401(k)