Find Jobs
Find Jobs Near You – Available Work in Your Location
Documentation Improvement Coordinator
Career Insights for Clinical Documentation Specialist
See where this job fits in the broader career landscape. Knowing your career path helps you see what's possible from here.
Scorecard
Based on Texas data
Review key factors to help you decide if this role fits your goals. How is this calculated?
What they do
A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
$67,278 / year median in Texas
+2% projected growth
Job Description
POSITION SUMMARY/RESPONSIBILITIES
Must be clinically competent in caring for the assigned inpatient population. Must work collaboratively with all members of the healthcare team.Reviews patient accounts through the appropriate review process for accurate and complete documentation of the care of the patient. Queries the provider to ensure that the accurate and complete documentation is recorded in the medical record. Concurrently reviews the documentation of the patients care and queries as appropriate following the
ACDIS/AHIMA
query brief guidelines to ensure complete and accurate documentation of a patient's care during their stay in the hospital.Promotes accurate documentation that reflects the appropriate risk of mortality (ROM) and severity of illness (SOI) resulting in maximum reimbursement. Maintains a strong understanding and knowledge of coding guidelines, ACDIS standards, Epic workflows, and 3M principles.
EDUCATION/EXPERIENCEGraduation from an accredited college or university with a bachelor's degree in nursing is preferred.
Three years recent, full-time hospital experience preferred.
Work experience in documentation improvement, case management, utilization review or hospital quality assurance is preferred. Must complete a Clinical Documentation Improvement Course within specified time of hire date.
LICENSURE/CERTIFICATIONCurrent license from the Board of Nurse Examiners of the State of Texas to practice as a registered nurse; National certification (e.g. CDS, CCRN, RNC, CEN, CNOR, OCN, ANCC, CAN, CPAN, CFRN, etc.) in related field is preferred.