Clinical Documentation Specialists assess medical records and documents for compliance with industry regulations. Their duties include analyzing medical information to assist healthcare providers, ensuring the accuracy of clinical documentation, and training staff on recordkeeping procedures. They may work at hospitals or healthcare facilities.
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Clinical Documentation Specialist Job Description Template
We are seeking a knowledgeable Clinical Documentation Specialist to oversee our facility's medical recordkeeping practices. In this role, you will be responsible for ensuring that clinical documentation complies with federal laws, training staff in medical recordkeeping practices, and analyzing medical information.
To ensure success, Clinical Documentation Specialists should exhibit extensive experience in a similar role and sound knowledge of clinical documentation regulations. A first-class Clinical Documentation Specialist should be a medical professional whose expertise translates into sound medical recordkeeping practices.
Clinical Documentation Specialist Responsibilities:
- Applying knowledge of medical terminology and procedures to evaluate clinical documents.
- Collecting medical information from healthcare providers and updating medical records.
- Verifying the accuracy of patient medical information and obtaining missing information.
- Monitoring diagnoses, treatments, and follow-up entries in medical records.
- Interpreting and preparing clinical reports for healthcare professionals and public health officials.
- Meeting with healthcare stakeholders to explain findings and facilitate actions.
- Ensuring that the content and storage of medical documents comply with federal laws.
- Training medical and administrative staff in standard medical recordkeeping procedures.
- Keeping abreast of advancements in the field of clinical documentation and changes in regulations.
Clinical Documentation Specialist Requirements:
- Associate's or Bachelor's Degree in Health Information Technology.
- Registered Health Information Technician (RHIT) preferred.
- Registered Nurse (RN) will be advantageous.
- Proficiency in Electronic Medical Record (EMR) software, such as eClinicalWorks and Praxis.
- A minimum of three years' experience in a similar role.
- Advanced knowledge of best practices in medical recordkeeping.
- In-depth knowledge of medical terminology, coding, and procedures.
- Extensive experience in collecting and interpreting medical information, as well as training staff.
- Ability to keep informed of advancements and regulations in clinical documentation.
- Excellent organizational and communication skills.
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