The clinical documentation specialist collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction, and submission of accurate data required by CMS. Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a DRG based payer (Medicare, Medicaid). Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates all clinical staff concerning accurate and effective clinical documentation

EDUCATION: Graduate of accredited school of nursing; BSN preferred, or a graduate in a related health field such as Health Care Administration, Health Information Management, Coding, or College of Medicine. Strong knowledge of disease processes, treatment, and outcomes of treatment modalities.

 CERTIFICATION/LICENSES: Licensed as a Registered Nurse in the State of New Mexico or Certification as a Clinical Documentation Specialist (CCDS) or CPC-H. BLS certification issued through American Heart Association, required.

 SKILLS:

• Basic computer skills in word processing and spreadsheet utilization.
• Excellent written and verbal communication skills.
• Proficient in computer use (desktop and/or laptop).
• Demonstrates basic knowledge regarding HIM coding standards.
• Analytic skills necessary to accurately assess patient medical records.
• Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes.
• Ability to be flexible and adjust to workload/assignment changes and interruptions.

 EXPERIENCE: Minimum of 5 years recent experience in an acute care setting in a clinical nursing field required. Prior experience in clinical documentation improvement, utilization