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What Is a Clinical Documentation Specialist and How to Become One

What Is a Clinical Documentation Specialist?

A clinical documentation specialist, also called a medical coder or billing specialist, oversees all types of health care documents. As a clinical documentation specialist, your responsibilities and duties include checking patient records are accurate and complete and entering data into the electronic records system. You also utilize your expertise to examine patient records and correctly code all diagnoses and procedures according to the national medical billing coding system to ensure proper billing to insurance companies. This position requires a keen eye for detail.

How to Become a Clinical Documentation Specialist

Though some clinical documentation specialist positions require an associate degree in medical billing or a related field, some clinical documentation specialist jobs only need a postsecondary training certificate and provide on-the-job training. These education programs provide the basics of anatomy, physiology, computer technology, and privacy laws to gain the skills and qualifications you need to fulfill your responsibilities in this career. Research additional qualifications concerning certification and licensing in the state you wish to work.

What Is Clinical Documentation?

Clinical documentation is the umbrella term used to describe all health care document management. Clinical documentation specialists gather and process these documents. Their duties include taking patient histories, checking patient records are correct and complete, assigning medical billing codes to treatments, and monitoring document systems for security issues. Clinical documentation is a vital part of the health care industry. It ensures patient privacy, accurate treatment, and proper patient and insurance billing. Attention to detail is essential in this field.

Clinical Documentation Specialist Job Description Sample

With this Clinical Documentation Specialist job description sample, you can get a good idea of what employers are looking for when hiring for this position. Remember, every employer is different and each will have unique qualifications when they hire for a Clinical Documentation Specialist role.

Job Summary

Our hospital is looking for an experienced and detail-oriented Clinical Documentation Specialist to help us improve the quality of our recordkeeping processes. You will collaborate with the clinical documentation supervisor and medical coding staff to review patient medical records for accuracy and ensure documentation complies with all relevant governmental regulations. Meticulous evaluation of these records helps our physicians, nurses, and other health care staff provide the best care possible to our patients. Applicants must have a current nursing license and at least three years of experience in the medical field.

Duties and Responsibilities

  • Review medical charts for accuracy of coding and documentation
  • Collaborate with staff to determine areas in need of closer review
  • Train physicians and other medical staff on proper documentation procedures to ensure consistency and accuracy
  • Update database

Requirements and Qualifications

  • Current LPN or RN license
  • Medical coding certification (AAPC, AHIMA, CRC, CCS-P, CCS, CPC)
  • At least three years of experience in the medical field
  • Knowledge of Medicare coding a plus
  • Excellent organization and communication skills
  • Attention to detail
  • Proficient in Microsoft Office
  • Valid driver's license and reliable transportation