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Clinical Documentation Specialist
Tenet HealthcareClinical Documentation Specialist enhancing clinical documentation accuracy and educating healthcare staff at Delray Medical Center. Responsible for quality services and compliance in documentation practices.
About the role
Key responsibilities & impact- Reports to the Market Clinical Documentation Specialist Manager
- Works collaboratively with medical, nursing and ancillary staff, case managers and coders
- Improves accuracy, quality and completeness of clinical documentation
- Performs initial and follow up reviews of selected patient accounts
- Ensures accuracy and completeness of clinical information for quality services
- Oversees clinical documentation patterns and trends
- Educates members of the patient care team regarding clinical documentation needs
- Develops and conducts education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals
- Compiles, analyzes, and evaluates quality and clinical data
Requirements
What you’ll need- Graduate from an accredited School of Nursing with RN or LPN, BSN
- Graduate from an accredited School of Medicine with MD or MBBS (either foreign or domestic)
- Minimum of 1-year experience working as a CDI in an acute care hospital
- Graduate from an accredited Health Informatics program for clinical Documentation (preferred)
- 1 – 2 -years’ experience or more working as a CDI in an acute care hospital (preferred)
- 3 - years’ experience or more in a clinical setting with patient care (preferred)
- Required certifications: Either RN, or LPN with an active license; Or MD, or MBBS
- Preferred certifications: BSN; CDI related certificate (RHIA, RHIT, CCS, CDIP, CCDS); USMLE Certificate
Benefits
Comp & perks- Medical, dental, vision, and life insurance
- 401(k) retirement savings plan with employer match
- Generous paid time off
- Career development and continuing education opportunities
- Health savings accounts, healthcare & dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical documentation improvementdata analysisquality evaluationpatient account reviewclinical data compilation
Soft Skills
collaborationeducationcommunicationleadership
Certifications
RNLPNBSNMDMBBSRHIARHITCCSCDIPCCDS