The Clinical Documentation Management Professional is responsible for facilitating the improvement in the overall quality and completeness of medical documentation. Promotes appropriate clinical documentation through appropriate interaction with physicians, nursing staff, other patient caregivers, and Health Information Management/Medical records’ coding staff. On an ongoing basis educates all members of the patient care team on documentation guidelines including, but not limited to the CMS Present on Admission reporting requirements. Impacts the quality of clinical documentation and in turn affects the financial reimbursement of the institution.
Education/Experience: Bachelor’s Degree in Nursing and/or Health Information Management with 2-5 years field related, job related experience with a minimum 2 years clinical experience or 5 years of inpatient
- A high level of clinical skills required to participate collaboratively with all members of the care team.
- Knowledge of nursing acute care regulatory/accreditation requirements preferred.
- Strong critical thinking skills and exceptional ability to integrate knowledge.
- Excellent observation, communication and decision making abilities.
- Ability to assess, evaluate, and teach all members of the care team.
Licensure/Certification/Registration: RN, RHIA/RHIT,CCS
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