RN, Clinical Documentation Specialist

Saint Francis Health System Muskogee , OK 74403

Posted 3 months ago

Job Summary: The Clinical Documentation Specialist facilitates accurate documentation for severity of illness and quality in the medical record.

Keep functions include extensive record review and direct interaction with medical, nursing, and ancillary staff to capture clinical documentation at the point of care; and health information staff to assure appropriate use of available clinical documentation to reflect accurate diagnosis, co-morbidities, and care provided for the patient.

It requires independent decision making of a complex nature based on training in the clinical documentation process. Active participation in team meetings and staff education on the clinical documentation improvement process is a key role.

Education: Completion of a state approved Registered Nurse program. Licensure, Registration and/or Certification: Valid State of Oklahoma Registered Nurse License.

Work Experience: Minimum of 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU. Knowledge, Skills and Abilities:

Organizational, analytical and writing skills.

Ability to demonstrate critical thinking, problem solving and deductive reasoning skills. Excellent interpersonal skills and ability to develop relationships.

Excellent time management.

Knowledge of regulatory guidelines including but not limited to Medicare Part A. Knowledge of Pathophysiology and Disease Process and ability to pass a written clinical competency exam and processes.

Basic computer skills.

Job Summary:
The Clinical Documentation Specialist facilitates accurate documentation for severity of illness and quality in the medical record.

Keep functions include extensive record review and direct interaction with medical, nursing, and ancillary staff to capture clinical documentation at the point of care; and health information staff to assure appropriate use of available clinical documentation to reflect accurate diagnosis, co-morbidities, and care provided for the patient.

It requires independent decision making of a complex nature based on training in the clinical documentation process. Active participation in team meetings and staff education on the clinical documentation improvement process is a key role.

Education: Completion of a state approved Registered Nurse program.

Licensure, Registration and/or Certification: Valid State of Oklahoma Registered Nurse License.

Work Experience: Minimum of 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.

Knowledge, Skills and Abilities:

Organizational, analytical and writing skills.

Ability to demonstrate critical thinking, problem solving and deductive reasoning skills. Excellent interpersonal skills and ability to develop relationships.

Excellent time management.

Knowledge of regulatory guidelines including but not limited to Medicare Part A. Knowledge of Pathophysiology and Disease Process and ability to pass a written clinical competency exam and processes.

Basic computer skills.



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RN, Clinical Documentation Specialist

Saint Francis Health System