Clinical Documentation Specialist Qualifications
• ** Must have at least one of the following:**
• ** Must have all of the following:**
Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.
• Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and and highest level of SOI/ROM is achieved for the level of service rendered to all patients
• Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis
• Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities
• Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses , treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses – obtaining missing information via a query when necessary
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