Clinical Documentation Specialist RN

As a Clinical Documentation Specialist, you will provide critical expertise in medical record accuracy and integrity, supporting patient care quality and financial compliance.

You will review clinical documentation, query physicians for clarification and specificity, educate providers on documentation best practices, and ensure records accurately reflect the patient's severity of illness and complexity of care.

Key responsibilities include:

• Reviewing medical records for completeness and accuracy related to severity of illness and quality
• Using CDMP documentation strategies for inpatient review
• Identifying opportunities for documentation improvement
• Initiating CDMP severity worksheets for inpatients
• Formulating clinically credible documentation clarifications
• Requesting documentation clarifications for severity of illness, core measures, and patient safety