Clinical Documentation Specialist

Position Summary

The Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation within the electronic health record. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing, other patient caregivers, and coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Works closely with coding to assist and/or coordinate in resolving documentation and coding discrepancies. Provides documentation training to clinicians and provides ongoing support. Ensures that documentation practices and processes comply with applicable regulatory guidelines and requirements. Participates in special projects when necessary. 

Job Responsibilities: 

• Manages assignments and projects as assigned. 
• Participates in the daily operations and activities of the Clinical Documentation Improvement (CDI) program to continually enhance documentation. 
• Utilizes most current documentation tools available. 
• Regularly and effectively communicates with clinical staff. 
• Collaborates with coding in an effort to maintain coding and documentation quality and compliance. Ensures that coding process and guidelines meet State and Federal requirements and standards. 
• Works with the medical staff to continuously improve clinical documentation to facilitate accurate coding through the use of compliant physician queries, when appropriate. 
• Facilitates communication of various professionals to support organizational goals related to documentation integrity, compliance, quality and coding. 
• Assists in development and delivery of education for both clinical and non-clinical staff. 
• Meets performance standards by setting goals and objectives, prioritizing work, and using available resources efficiently and effectively. 
• Stays abreast of the latest developments, advancements, and trends in the field of documentation improvement and coding by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and maintaining certification or licensure. Integrates knowledge gained into current work practices. 
• Participates in the training of new employees as needed. 
• Ensures that work is completed accurately and according to schedule. 

Minimum Qualifications: 

Current registered nurse (RN) license with a Bachelor's Degree in Nursing plus 2 years of experience in acute care, health care administration or commensurate experience.

Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) credential must be obtained within one year of hire. Experience with ICD-10-CM/PCS coding and DRG assignment. Outstanding oral, written and interpersonal skills. Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement. 

Preferred Qualifications: 

CCDS or CDIP upon hire plus 2 years of clinical documentation improvement experience

AAP/EEO Statement

Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law. Omega Healthcare also prohibits harassment of applicants or employees based on any of these protected categories.

Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances. If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at employeerelationsus@omegahms.com.

5 Years ICU/CCU/Med Surg Clinical Experience

2 Years CDI Experience