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Clinical Documentation Specialist

JOB SUMMARY:  
•    Responsible for facilitating improvement in inpatient clinical documentation through concurrent review of the medical record for accurate physician documentation of principal and secondary diagnoses 
based on clinical evidence present in the chart, application of official ICD-9 CM coding guidelines, and interaction with physicians and other clinicians.  Identifies opportunities for improvement in clinical 
documentation and queries the physician for clarification to support more specific diagnoses.

POSITION RELATIONSHIPS:
Reports to:  Department Director, Outcomes Management

Positions Supervised:  None

EDUCATIONAL REQUIREMENTS/PREFERENCES:
•    Graduate of an accredited school of nursing
•    Bachelors in Nursing required with current RN licensure in the State of Maryland

EXPERIENCE/REQUIREMENTS:
•    Minimum of five years of current clinical experience in an acute care setting;  critical care and/or medical  nursing experience; previous experience with clinical documentation improvement activities and case management desirable, .

KNOWLEDGE, SKILLS AND ABILITIES:
•    Requires demonstrated advanced problem solving abilities and competent clinical knowledge.
•    Ability to review and synthesize clinical information to determine if documentation clearly reflects the patient’s condition. 
•    Ability to effectively communicate with confidence and knowledge to health care team members. Is creative, diplomatic in dealing with physicians and other staff members. 
•    Highly effective interpersonal skills. 
•    Ability to work collaboratively in a team approach.
•    Ability to facilitate and negotiate issues through to resolution. 
•    Ability to work in a stressful environment, demonstrating good organization skills, a sense of humor and an ability to resolve conflict. 
•    Ability to work flexible hours as is required to meet department needs.  Ability to access information system programs and move throughout the hospital is required.
•    Requires computer knowledge.

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