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Clinical Documentation Specialist - Medical Records

St. Peters Health

Helena, MTJobSeen todaySeen in employer's feed today

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At a glance

Compensation
No compensation found
Location
Helena, MT
Work Authorization
Not specified

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Requirements

Credentials this posting asks for.

RN LicenseClinical Documentation Specialist Certification Within 2 Years

Job overview

The Clinical Documentation Specialist reviews inpatient medical records to ensure accurate documentation of diagnoses and procedures, assigns appropriate codes, supports quality assurance and reporting, and educates providers and staff on documentation practices.

Skills & qualifications

RequiredNice to have

Skills

CommunicationAttention to DetailRelationship Building

Qualifications

RN LicenseRN or Healthcare Related DegreeClinical Documentation Specialist Certification Within 2 Years3 Years Clinical Experience2 Years Clinical Documentation ExperienceClinical Documentation Specialist or Inpatient Coding Certification

Full job description

This position provides concurrent clinical review of inpatient medical records to ensure accurate and complete documentation of diagnoses and procedures. Reviews clinical information, assigns appropriate codes, supports quality assurance and reporting efforts, and provides education to providers and staff on clinical documentation. Requires excellent communication skills, strong attention to detail, and the ability to build positive relationships with physicians while providing guidance in a respectful, non-confrontational manner.

KNOWLEDGE/EXPERIENCE: RN license with at least 3 years of clinical experience highly preferred. 2 years previous clinical documentation experience highly preferred. Clinical Documentation Specialist or Inpatient Coding Certification highly preferred. Strong attention to detail and a high level of accuracy required. Experience may be considered in lieu of certification.

EDUCATION: RN or Healthcare related degree required.

LICENSE/CERTIFICATION/REGISTRY: Clinical Documentation Specialist certification must be obtained within 2 years. If RN a current license is required.

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