POSITION PURPOSE AND SUMMARY:

Clinical Documentation Specialist facilitates internal process changes that bring together physicians, case managers, and coders to address clinical documentation opportunities for improvement. Work collaboratively with the physicians to improve documentation compliance with criteria requirements under the Inpatient Prospective Payment System, in order to eliminate payment errors upon patient discharge caused by incomplete/inaccurate physician documentation; as well as ensure clear and concise documentation.  Use clinical/nursing knowledge of documentation requirements to improve overall quality and completeness of clinical documentation of patient records on concurrent basis using a multidisciplinary team process. 

 

EDUCATION/EXPERIENCE:

Registered Nurse, BSN preferred, in State of Indiana Three to five years of clinical experience and case management/utilization management. Knowledge of MS-DRG prospective payment systems, basic knowledge of medical coding.