Clinical Documentation Specialist

Responsibilities: The Clinical Documentation Specialist will complete admission reviews and assign working Diagnosis Related Groups while ensuring accurate data entry in the Clinical Documentation Improvement database. They will collaborate with healthcare professionals to ensure the medical record accurately reflects the severity of illness and level of services provided.

Requirements: Candidates must have one or more relevant certifications from recognized organizations and a minimum of a high school diploma or equivalent experience. Preferred qualifications include 5 or more years of nursing experience in ICU and/or Emergency Department, along with previous Clinical Documentation Specialist experience.

Key skills: Clinical Documentation, Diagnosis Related Group, Medical Record, Collaboration, Healthcare, Nursing, Coding, Documentation Improvement, Physician Interaction, Data Entry, Quality Assurance, Patient Care, Regulatory Compliance, Problem Solving, Communication, Attention to Detail

Keywords: Clinical Documentation Specialist, Diagnosis Related Group, Clinical Documentation Improvement, Healthcare, Nursing, Certified Coding Specialist, Registered Health Information Administrator, Registered Health Information Technician, Certified Professional Coder, Clinical Documentation Professional, Wisconsin Board of Nursing, ICU, Emergency Department, Medical Record, Patient Care, Collaboration, Data Entry