Clinical Documentation Specialist

Baptist Health is the largest healthcare system serving central Alabama, providing comprehensive hospital-based and outpatient services to nearly 60 percent of the residents in Montgomery, Autauga and Elmore counties. To learn more about Baptist Health, visit us at https\://www.baptistfirst.org.

The RN - Clinical Documentation Improvement (CDI) Specialist is responsible for facilitating the integrity in the overall quality and completeness of provider-based clinical documentation in the medical record. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate. The goal is to ensure that documentation in the EMR accurately reflects the severity of illness of the patient. This position may have additional duties assigned as needed.

• Degree in Nursing, Bachelor's degree in Nursing preferred.
• Minimum 3 years coding and reimbursement in acute care setting.
• Experience with DRG's preferred. 
• RN license required,
• Certified Clinical Documentation Specialist (CCDS) preferred
• Skill in the use of computers.
• Ability to effectively manage time and schedules.
• Ability to monitor and maintain quality control standards.
• Ability to work both independently and in a team environment.
• Knowledge of clinical documentation requirements.
• Knowledge of organizational structure, workflow, and operating procedures.
• Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures.
• Extensive knowledge of ICD 9 and reimbursement methodologies.