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RN | Clinical Documentation Specialist

This job posting is no longer active.

Macon, GA, United States
Job ID: 61936
Job Family: Patient Accounting/Registration
Status: Full Time
Shift: Day
Job Type: Regular
Department Name: 12011053141601-Patient Access

Overview

The Clinical Documentation Specialist conducts concurrent reviews of the medical record and often serves as a liaison to the medical staff to ensure that the medical record is complete and accurate and provides a clear picture of the patient’s clinical record and treatment.   Therefore, the CDS is often tasked with obtaining appropriate clinical documentation to ensure that the level of service rendered to the patient and the clinical complexity of the patient’s condition are completely and accurately documented. The CDS helps to identify potential gaps in clinical documentation and ensures that the severity of the patient’s illness, the intensity of services, and the risk of mortality are appropriately reflected in the record.  Works with coding staff to support appropriate DRG Validation and reimbursement to the hospital.   

 

What we offer: 

  • Competitive pay 

  • Evidence-based nursing practice 

  • Comprehensive Benefits (Medical, Dental, Vision, Health Savings and Spending Account options) 

  • 403b Retirement Savings Plan with employer-matching contributions 

  • Paid Time Off (PTO) and Extended Illness Benefit (EIB) 

  • Education Assistance Plans  

  • Employee discounts/perks 

  • Employee Fitness and Wellness Center 

 

What you will need: 

  • Associate's or Bachelor's degree in nursing.

  • Current valid Georgia nursing license or eNLC nursing license. 

  • Three (3) to Five (5) years clinical experience in an acute care hospital, preferably with ICU and/or Medical/Surgical experience. 

  • Certified Clinical Documentation Specialist  (CCDS) and/or Certified Coding Specialist (CCS) preferred. 

  • Working knowledge and experience in ICD10 Diagnosis and Procedure Coding.  Common Procedural Terminology (CPT) coding knowledge preferred.