DUTIES: The Clinical Documentation Specialist facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients. The CDS will gather and analyze information pertinent to documentation findings and outcomes. Daily evaluations of documentation by medical staff and healthcare team. Provides education related to compliance and documentation issues.
EDUCATION: Must be a graduate of an NLN or CCNE accredited nursing program
LICENSURE: Currently licensed as a Registered Nurse in the State of Indiana.
EXPERIENCE: 2 years of clinical experience in an acute care setting. Prefer recent clinical documentation improvement experience, utilization review or case management experience. Documented clinical documentation program training or commit to 2 years onsite learning. Will be willing to send the right candidate to an 8 week paid training course with a 2 year commitment.