Clinical Document Specialist, RN

Nov 05 2018
Category: Healthcare
Job Description






The Clinical Documentation Specialist (CDS) focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data.  The CDS performs concurrent clinical documentation chart reviews to validate that the medical record appropriately describes the patient’s severity of illness and risk of mortality.  The CDS develops compliant physician queries guided by the American Health Information Management Association’s (AHIMA) “Ethical Standards for Clinical Documentation Improvement Professionals.”  In addition, the CDS may review medical records retrospectively, in accordance with the Health Information Management’s policies and procedures to identify whether or not the physician responded to a query placed concurrently.  These functions are performed in accordance with all applicable laws and regulations in the state of Hawaii.




Performs tedious chart reviews immediately upon admission to capture relevant documentation to support ICD-10 codes necessary to comprise a complete rehabilitation chart needed within the first three days of admission to obtain an accurate length of stay per individual patient admitted.  The chart reviews will include documents from the referring facility and may require n inquiry follow up call with the surgeon to identify specific information necessary to accurately identify ICD-10 codes.  




Keeps the Senior Vice President, Patient Care Services and IRF-PAI Coordinator informed of issues related to patient care, operations, risk and continuous improvement activities, on a timely basis. 








·         Current State of Hawaii RN licensure. 

·         Current healthcare CPR certification within one (1) month from date of hire (Healthcare provider course or equivalent which includes neonatal, child, adult and AED’s) and maintains certification thereafter.

·         Completion of competencies and other job-related and REHAB requirements. 



·         Associate’s Degree in Nursing with at least five (5) years of  acute care/rehabilitation experience within the past five (5) years; or

·         Bachelor’s Degree in Nursing with at least two (2) years of acute care/rehabilitation experience within the past five (5) years.

·         Completion of ICD-10 coding course within 12 months of hire.



·         Three (3) years of rehabilitation or acute care medical-surgical experience.

·         Knowledge of clinical documentation requirements as well as ICD-10 coding guidelines.

·         Detail oriented with exceptional organizational skills.

·         Knowledge of Inpatient Rehabilitation Facility Patient Assessment Indicators.

·         Knowledge of medical record documentation requirements and standards.

·         Knowledge of state, federal and other rules and regulations, including the JC and Nurse Practice Act. 

·         Excellent communication, interpersonal, problem-solving and analytical skills.