CLINICAL DOCUMENTATION SPECIALIST SKILLS, EXPERIENCE, AND JOB REQUIREMENTS

Published: July 15, 2024 - The Clinical Documentation Specialist should have a strong grasp of clinical documentation, payor issues, and Medicare coding and reimbursement structures to ensure compliance and optimize funding. This role requires expertise in analyzing care delivery documentation systems and medical records along with the ability to effectively communicate and collaborate with physicians and health information staff. The specialist also has exceptional analytical, problem-solving, and communication skills to maintain accuracy and foster positive professional relationships.

Essential Hard and Soft Skills for a Standout Clinical Documentation Specialist Resume
  • Medical Coding
  • Clinical Data Management
  • Electronic Health Record Systems
  • Medical Terminology
  • HIPAA Compliance
  • Quality Assurance
  • Data Analysis
  • Documentation Software Proficiency
  • ICD-10 Coding
  • Regulatory Knowledge
  • Attention to Detail
  • Communication
  • Problem Solving
  • Confidentiality
  • Adaptability
  • Team Collaboration
  • Organizational Skills
  • Time Management
  • Critical Thinking
  • Empathy

Summary of Clinical Documentation Specialist Knowledge and Qualifications on Resume

1. BS in Nursing with 5 years of Experience

  • Registered Nurse license issued by the state in which the team member practices.
  • Proven working experience in an acute inpatient environment.
  • Ability and desire to learn and develop skills necessary to perform the Clinical Documentation Program.
  • Knowledge of Clinical Documentation payor issues including requirements and reimbursement policies
  • Working knowledge of Medicare reimbursement and coding structures.
  • Knowledge of care delivery documentation systems and related medical record documents.
  • Excellent analytical and interpersonal communication skills necessary to collaborate with physicians and health information staff.
  • Demonstrated ability to work well with physicians and other professionals directly and positively.
  • Excellent written and verbal communication and critical thinking skills.
  • Manual dexterity for operating computer and calculator.

2. BS in Health Information Management with 2 years of Experience

  • Must have a Registered Nurse (RN)
  • Certified Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS must be obtained within 1 year of hire.
  • Working experience as an inpatient or outpatient CDIS I
  • Proficient in the use of department CDI software 
  • Able to utilize the reporting functions to develop materials for meetings and presentations
  • Knowledge of physician documentation in the inpatient or outpatient setting
  • Knowledge of inpatient or outpatient payment methodologies
  • The ability to close, distance, and color vision
  • The ability to work under stress and meet deadlines.
  • Ability to follow standard precautions using personal protective equipment for procedures.

3. BS in Biology with 4 years of Experience

  • Working experience with Inpatient CDI, Coding, or DRG Assurance including RN/RHIT/RHIA with CCS/CCDS/CDIP
  • A combined clinical and CDI work experience in acute care hospital settings.
  • Experience working with Inpatient CDI, DRG assurance, or Coding work experience
  • Visual acuity to facilitate the review of written documents/computer screens, and medical records, and to record information accurately.
  • Clear oral communication and hearing acuity for receiving instructions and conversing on a standard telephone.
  • Functional speech and hearing allow for effective communication of instructions and conversation over the telephone.
  • The ability to operate all equipment necessary to perform the job.
  • Critical care or strong medical/surgical background
  • Ability and desire to learn and develop skills necessary to perform the Clinical Documentation Program. 
  • A combination of Registered Nurse (RN) or Registered Health Information Technician/Administrator (RHIT/RHIA) with certification in coding or clinical documentation improvement 

4. BS in Healthcare Administration with 2 years of Experience

  • Clinical experience in an acute care setting with CDI experience.
  • Knowledge of care-delivery documentation systems and related medical record documents
  • Knowledge of age-specific needs and the elements of disease processes and related procedures
  • Understanding of CDI and encoder applications
  • Excellent communication and critical thinking skills
  • Working knowledge of Medicare reimbursement and coding structures
  • Ability to work independently in a time-oriented environment
  • Must have legible handwriting
  • Basic computer skills – MS Word, Excel and PowerPoint
  • Certified CCDS/CDIP and/or CCS with 3M360-DRG Assurance experience

5. BS in Medical Informatics with 3 years of Experience

  • Knowledge of Clinical Documentation payor issues including requirements and reimbursement policies helpful.
  • Working knowledge of Medicare reimbursement and coding structures.
  • Knowledge of care delivery documentation systems and related medical record documents.
  • Excellent analytical and interpersonal communication skills necessary to collaborate with physicians and health information staff.
  • Demonstrated ability to work well with physicians and other professionals directly and positively. 
  • Excellent written and verbal communication and critical thinking skills.
  • Knowledge of clinical documentation requirements that identify clinical conditions or procedures.
  • Excellent interpersonal skills including excellent verbal and written communication skills
  • Utilize and demonstrate excellent critical thinking, problem-solving and deductive reasoning skills.
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