The Clinical Documentation Specialist is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physiciansâ™ clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. The CDS will participate in team meetings and education of staff is a key role.
Accurate and timely record review
Recognize opportunities for documentation improvement
Ability to access, manage and update patient medical records through Hospital Electronic Medical Record Information System
Formulate clinically credible queries
Effective and appropriate communication with physicians
Timely follow up on all cases especially those with queries
Participate in Task Force meetings
Manage multiple priorities
Knowledge of Medicare Part A
Familiar with Medicare Part B
Communicates with HIM staff and resolves discrepancies
The information above is for summary purposes, and is not intended to be a comprehensive list of essential functions.
Bachelor degree related to the applicable clinical area of responsibility, such as nursing, nursing administration, rehabilitation, or other clinical field, required
Valid license or certification in the applicable clinical area of responsibility, in the State of practice, required
Five years of experience in progressive clinical positions, required
Excellent communication and interpersonal skills, required
SCL Health is a faith-based, nonprofit healthcare organization that operates eight hospitals, four safety net clinics, one children’s mental health center and more than 190 ambulatory service centers in three states – Colorado, Kansas and Montana. The health system includes 15,000 full-time associates and more than 500 employed providers.