Clinical Documentation Specialist

Health Information Services

Full Time -80 hours


as scheduled

In an environment of continuous quality improvement, the Clinical Documentation Specialist is responsible for reviewing physician documentation practices to comply with governmental regulations for standardized patient care and quality of care core measure indicators.  In this role, the Clinical Documentation Specialist will complete chart reviews and facilitate documentation improvement through communication with the physicians in order to maintain compliance requirements for data abstraction, analysis, and reporting. Exhibits the MHS Standards of Excellence and exercises strict confidentiality at all times.


Job Requirement:

·          Graduate of an accredited school of nursing with current licensure in the State of Ohio as a Registered Nurse required

·          Minimum of 5 years recent experience in an acute care setting or managed care environment required

·          Strong organization skills, self-directed, flexible, able to adapt to rapidly changing regulatory requirements

·          Ability to analyze, interpret and assimilate information from various sources based on technical and experience-based knowledge

·          Demonstrated knowledge in using clinical information systems, excel spreadsheet, and reporting and/or graphing capabilities and web access to input and research information

·          Possesses effective interpersonal skills, can work across departmental boundaries, facilitates problem resolution, and maintain a professional demeanor in difficult situations

·          Demonstrate ability to work effectively with physicians

·          Strong working knowledge of hospital organization, operations and its interaction with medical staff and other hospital departments

·          Possess excellent verbal and written communication skills


Job Functions:

1.     Conducts concurrent and retrospective documentation review.

2.     Assesses learning needs in order to plan and participate in education programs for physicians, coding specialists and clinical staff.

3.     Maintains responsibility/accountability for professional development and maintaining licensure.

4.     Functions as a liaison person in analyzing and evaluating physician documentation practices.

5.     Takes responsibility to identify barriers to complete timely physician documentation and promote improvements in work processes

6.     Utilizes computer systems effectively including 3M encoder, Meditech, Chartmaxx, Excel Spreadsheet, vendors, software abstracting tools, and other systems as appropriate.

7.     Assumes all other duties and responsibilities as necessary.