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Clinical Documentation Specialist

Company ProMedica
Update 5 Day ago
Job Description:
ProMedica is a locally-owned, nonprofit health system
providing quality health care services to 27 counties in
northwest Ohio and southeast Michigan. We’re a network
of hospitals, physicians, health care professionals,
researchers, and specialty clinics and facilities. We
offer a full range of diagnostic, medical, and surgical
specialties in areas such as emergency medicine and
trauma, heart and vascular, oncology, orthopedics,
neurology, women’s services, and children’s services.
Position Summary
The Clinical Documentation Specialist (CDS) is
responsible for reviewing medical records to facilitate
the accurate representation of the severity of illness.
This involves extensive record review, interaction with
physicians, clinical staff and HIM coding professionals.
Active participation in team meetings and education of
staff in the clinical documentation improvement program
are key functions of this role.
  • Performs daily Clinical Documentation Improvement
Program tasks including extensive medical record
review, identification of opportunities for
documentation improvement, formulation of
clarifications, as well as compliant and effective
communication with physicians and other clinical
staff to obtain needed documentation.
  • Demonstrates knowledge of DRG methodologies and
coding guidelines related to clinical documentation
improvement and is able to effectively apply those
guidelines and identify opportunities.
  • Formulates clinically credible and compliant
documentation clarifications and addresses
clarifications and compliance with physicians,
clinical staff and HIM coding professionals as
  • Understands and communicates differences between
Medicare and commercial payer guidelines and how
they impact DRG assignment and other data reporting
  • Develops and delivers education to physician and
clinical staff related to clinical documentation
  • Collaborates effectively with team to ensure the
team accomplishes expected outcomes; demonstrates
effective communication and conflict management
  • Effectively manages multiple priorities and
demonstrates persistence in achieving targets.
  • Performs other related duties as assigned.
  • RN with active license required, or RHIA/RHIT
required; BSN preferred.
  • CCS or CDIP credentials preferred.
  • Experience with acute care inpatient coding or
clinical documentation improvement preferred.
  • Strong interpersonal skills and communication skills
  • Experience working with Electronic Medical Record
(EMR) and coding systems preferred.
  • Ability to input data into computer required.
  • Must be able to move about hospital and between
workstations; and prolonged periods of standing.
  • Must maintain continuous education and enhance
knowledge in area of specialty.
Qualified applicants will receive consideration for
employment without regard to race, color, national
origin, ancestry, religion, sex, pregnancy, sexual
orientation, gender identity or gender expression, age,
disability, military or veteran status, height, weight,
familial or marital status, or genetics.
Equal Opportunity Employer/Drug-Free Workplace