Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Educates members of the patient care team regarding documentation guidelines.
EXPERIENCE AND EDUCATION:
MINIMUM REQUIRED: Associate's degree in Nursing and two to four years clinical experience in acute hospital setting with demonstrated expertise in Med/Surg, OB, Trauma, ICU, and/or CCU.
PREFERRED: MD, DO degree from an accredited medical school or bachelor’s degree in Nursing. Prior coding or Clinical Documentation Improvement (CDI) program experience.
MINIMUM REQUIRED: One of the following: Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), or Current CA. Registered Nurse License.
PREFERRED: Certified Clinical Documentation Specialist (CCDS) certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) or Certified Documentation Improvement Practitioner (CDIP) through American Health Information Management Association (AHIMA).