Discover the essential requirements, duties, responsibilities, and skills needed for a Clinical Documentation Specialist job description.
What does a Clinical Documentation Specialist do?
A clinical documentation specialist is responsible for reviewing medical records and documents to ensure they meet industry regulations. They work to make sure that healthcare providers have accurate and complete information for patient care. These specialists are often employed by hospitals or other healthcare facilities.
Job Description
We are looking for a knowledgeable clinical documentation specialist to oversee our facility's medical recordkeeping practices. In this role, you will be responsible for making sure that our clinical documentation meets federal laws, training staff in recordkeeping procedures, and analyzing medical information.
To be successful in this role, you should have previous experience in a similar position and a solid understanding of clinical documentation regulations. A top-notch clinical documentation specialist should be a medical professional who can use their expertise to maintain accurate and compliant medical records.
Job Duties and Responsibilities
- Evaluating clinical documents using medical terminology and procedures.
- Gathering medical information from healthcare providers and updating records.
- Verifying the accuracy of patient information and filling in any missing details.
- Tracking diagnoses, treatments, and follow-up information in medical records.
- Interpreting and creating reports for healthcare professionals and public health officials.
- Meeting with healthcare stakeholders to explain findings and take necessary actions.
- Ensuring that medical documents comply with federal laws and are stored properly.
- Training medical and administrative staff on standard recordkeeping procedures.
- Staying up-to-date on advancements and changes in clinical documentation regulations.
Requirements and Qualifications
- Associate's or bachelor's degree in health information technology.
- Preferably certified as a Registered Health Information Technician (RHIT).
- Registered Nurse (RN) experience is a plus.
- Proficiency in Electronic Medical Record (EMR) software, such as eClinicalWorks and Praxis.
- At least 3 years of experience in a similar role.
- Extensive knowledge of best practices in medical recordkeeping.
- Thorough understanding of medical terminology, coding, and procedures.
- Proven experience in gathering and interpreting medical information, as well as training staff.
- Ability to stay informed about advancements and regulations in clinical documentation.
- Excellent organizational and communication skills.
Clinical Documentation Specialist Salary
The earning potential of a Clinical Documentation Specialist can vary significantly based on factors such as geographic location, industry, professional experience, educational background, and the specific employer. On average, the annual salary for an Clinical Documentation Specialist in the United States is approximately $62155.