The Clinical Documentation Specialist is responsible for the evaluation of physician documentation utilizing their clinical expertise to ensure the patients’ severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy. They provide guidance to the physicians nursing and ancillary staff on clinical documentation best practices. They must be self motivated and be adaptive to change.

+ Responsible for the day to day evaluation of inpatient documentation in accordance with the Clinical Documentation Program requirements.
+ Ensures the accuracy and completeness of clinical information which is used for measuring and reporting physician and hospital outcomes.
+ Communicate with members of the medical staff on an ongoing basis to assure the documentation in the medical record adequately reflects the diagnoses being treated and the procedure performed.
+ In addition to the above job responsibilities, other duties...