Clinical Documentation Specialist

White River Health System

Job Description:


*WRMC-Medical Records





Job Details:

Reviews medical records concurrently and queries physicians for clarification and specificity of documentation.  Also develops and coordinate educational and training seminars regarding appropriate documentation required for complete and accurate coding.

Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality.

Required Qualifications:

  • RN or LPN with good working relationship with physicians.    
  • Minimum 3 years previous clinical experience; preferably ER, ICU or Med-Surg
  • Prior experience in clinical documentation improvement, ICD Coding and MS-DRGs preferred.                                                                              
  • Prior experience educating physicians/providers preferred.
  • Previous experience working in a clinical documentation improvement department or as a consultant strongly encouraged.

This individual must possess a comprehensive knowledge of medical terminology, disease processes and clinical competency.

Education Qualifications:

Active RN or LPN license

ASN preferred; LPN with appropriate experience will be considered

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