Clinical Documentation Specialist

The Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation within the electronic health record. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing, other patient caregivers, and coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Works closely with coding to assist and/or coordinate in resolving documentation and coding discrepancies. Provides documentation training to clinicians and provides ongoing support. Ensures that documentation practices and processes comply with applicable regulatory guidelines and requirements. Participates in special projects when necessary.