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Clinical Documentation Specialist – Part Time
UMMC Police. Support and review inpatient medical records to improve the quality, completeness, clinical severity, and accuracy of clinical documentation for DRG-based or APR-based payor populations .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement, including the ability to review and enhance inpatient medical records for accuracy and compliance. Proficient in collaborating with healthcare providers and utilizing evidence-based clinical guidelines to support patient care.
Highest-signal resume keywords
RN LicenseClinical Documentation ImprovementEvidence-Based Clinical GuidelinesAnalytical SkillsUtilization Management
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Inpatient Medical Record ReviewICD-10 Inpatient Coding GuidelinesClinical Severity AssessmentDocumentation ComplianceRisk ManagementQuality IndicatorsClinical Indicator EvaluationVerbal and Written QueriesPatient Diagnosis SupportComputer Proficiency
Soft Skills
Communication SkillsProblem-Solving SkillsCollaboration Skills
Certifications & Qualifications
Valid RN License
Industry Keywords
Acute CareUtilization ReviewCase ManagementQuality ManagementEmergency DepartmentIntensive Care UnitMedical-SurgicalTraumaSurgical ServicesRegulatory Guidelines
About the role
Key responsibilities & impact- Support and review inpatient medical records to improve the quality, completeness, clinical severity, and accuracy of clinical documentation for DRG-based or APR-based payor populations
- Review inpatient medical records within 24–48 hours of admission for accuracy, completeness, compliance, and documentation opportunities
- Collaborate with physicians and healthcare providers to promote documentation improvement
- Formulate basic compliant verbal or written queries to clarify conflicting, ambiguous, or nonspecific documentation
- Identify and evaluate clinical indicators supporting accurate patient diagnoses
- Apply current and emerging techniques to improve patient-care documentation and record accuracy
- Escalate issues to Senior Clinical Documentation Specialists, providers, or administrators when appropriate
- Collaborate with senior CDS staff on complex cases and educational needs
- Maintain understanding of risk management and quality indicators, including PSIs, HACs, and PPCs
Requirements
What you’ll need- Two (2) years of nursing experience in Acute Care, Utilization Review, Case Management, and/or Quality Management
- Valid RN license
- Proficient knowledge of evidence-based clinical guidelines
- Excellent computer skills and proficiency with related software applications
- Excellent verbal and written communication skills
- Excellent analytical and problem-solving skills
- Prior nursing experience in the Emergency Department (ER), Intensive Care Unit (ICU), Medical-Surgical (Med-Surg), Trauma, or Surgical Services is preferred
- General awareness of ICD-10 Inpatient Coding Guidelines is preferred
- Proficient knowledge of resource and utilization management and regulatory guidelines is preferred