Clinical Documentation Specialist

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The Clinical Documentation Specialist is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. The CDS will participate in team meetings and education of staff is a key role.
  • Accurate and timely record review
  • Recognize opportunities for documentation improvement
  • Ability to access, manage and update patient medical records through Hospital Electronic Medical Record Information System
  • Formulate clinically credible queries
  • Effective and appropriate communication with physicians
  • Timely follow up on all cases especially those with queries
  • Participate in Task Force meetings
  • Manage multiple priorities
  • Knowledge of Medicare Part A
  • Familiar with Medicare Part B
  • Communicates with HIM staff and resolves discrepancies
The information above is for summary purposes, and is not intended to be a comprehensive list of essential functions.

Bachelor's degree related to the applicable clinical area of responsibility, such as nursing, nursing administration, rehabilitation, or other clinical field, required
Valid license or certification in the applicable clinical area of responsibility, in the State of practice, required
Five years of experience in progressive clinical positions, required
Excellent communication and interpersonal skills, required
Organization: St. Mary's Medical Center, Grand Junction, CO
Primary Location: CO-Grand Junction
Department: SYS-Clinical Doc Improvement
Schedule: Full-time
Shift: Day Shift
FTE: 1.0
Job Number: 18000617
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