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Clinical Documentation Specialist
Center for Health Care Strategies. Conduct concurrent and retrospective reviews of medical record documentation for accuracy, completeness, patient condition, and services performed .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Expertise in medical record documentation, ICD-10 coding, and clinical documentation improvement is essential, along with strong collaboration and communication skills to educate providers and enhance documentation practices.
Highest-signal resume keywords
ICD-10-CM/PCS CodingClinical Documentation Improvement (CDI)Registered Nurse LicenseEHR Documentation ToolsPediatric Nursing Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical TerminologyAnatomyPhysiologyPharmacologyDisease ProcessesDRG AssignmentRisk AdjustmentQuality ReportingDocumentation EducationDocumentation Review
Soft Skills
CollaborationCommunicationEducationProblem-SolvingTrend Identification
Tools & Technologies
EpicEHR SystemsDocumentation TemplatesSmart PhrasesTracking Tools
Certifications & Qualifications
CDI CertificationCoding CertificationRegistered Nurse License
Industry Keywords
Inpatient SettingsOutpatient SettingsPediatric NursingAPR-DRGMS-DRGRevenue CycleUtilization ManagementQuality TeamsPhysician AdvisorsBilling-Supporting Documentation
About the role
Key responsibilities & impact- Conduct concurrent and retrospective reviews of medical record documentation for accuracy, completeness, patient condition, and services performed
- Support accurate ICD-10-CM/PCS coding, DRG assignment, severity of illness, risk of mortality, reimbursement, risk adjustment, and quality reporting
- Collaborate with coding, physicians, physician advisors, quality teams, utilization management, revenue cycle, and clinical teams
- Deliver documentation education to providers, including risk stratification, chronic conditions, and billing-supporting documentation
- Develop templates, smart phrases, and other documentation tools with clinical teams
- Monitor and improve patient chart documentation in inpatient and outpatient settings
- Review inpatient records within 2 days of admission and identify documentation opportunities and problem-list inaccuracies
- Attend multidisciplinary patient rounds
- Communicate documentation opportunities and ICD-10 specificity through verbal or written queries; track queries and response rates in Epic
- Design and implement EHR documentation tools and educational programs with the physician champion
- Arrange education for new providers after onboarding
- Identify documentation trends and improvement opportunities and report them to attending groups
- Maintain expert knowledge of EHR clarification, presentation, and tracking tools and current ICD-10 requirements
- Understand APR-DRG and MS-DRG methodologies
- Review denials and identify root causes
- Identify strategies for sustained process changes supporting complete and accurate clinical documentation
- Maintain communication with hospital and professional billing coding staff, coding integrity, physician champion, and division leaders
Requirements
What you’ll need- Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes
- Registered Nurse, preferably with Pediatric nursing and/or CDI experience
- Minimum of 5 years experience in Pediatric nursing
- Active and unrestricted registered nurse license in the State of Delaware for NCH DE and/or the State of Florida for NCH FL
- CDI certification and/or coding certification preferred