Clinical Documentation Specialist Job Description

Clinical Documentation Specialist Job Description, Skills, and Salary

Get to know about the duties, responsibilities, qualifications, and skills requirements of a clinical documentation specialist. You can use our job description template in this article to produce your own. We also provide you with information about the salary you can earn as a clinical documentation specialist.

 

Who is a Clinical Documentation Specialist?

Clinical documentation specialists (CDS) are experts who examine a patient’s medical records to make sure the documentation is correct and current with the most recent knowledge about the patient’s ailment. Additionally, they document every stage of the therapeutic therapy process. Each patient’s information is organized by a clinical documentation specialist (CDS) in a medical facility. Due to the size of the assignment, professionals often collaborate. Each CD is in charge of ensuring that the healthcare professionals participating in a patient’s treatment are on the same page as well as adhering to HIPAA obligations and other confidentiality laws. A CDS takes care of this by examining the patient’s medical records, checking that the proper medical codes have been recorded, and capturing the information needed to deliver a full analysis of the patient’s health.

Such a role needs coordination between each CD and the multiple doctors and specialists they deal with. Additionally, it calls for a penchant for planning, effective communication abilities, and the capacity to perform effectively under pressure. Since many CDS employees interact with patients, empathy is another beneficial trait to possess. A clinical documentation specialist (CDS) analyzes diagnostic codes in medical records, locates missing diagnoses, and may follow up with physicians and nurses to fill in any gaps in the healthcare record. They bring a combination of clinical and technological expertise to their work.

Given the extensive paperwork that all healthcare procedures in the current healthcare system are required to keep, it is a crucial duty. Accurate health records are essential for delivering the finest medical care, expediting Medicaid billing procedures, and keeping the correct insurance documentation. A CDS is also responsible for ensuring that a healthcare facility manages patient records by HIPPA and other legal requirements.

Specialists in clinical documentation evaluate medical records and papers for adherence to industry standards. They must ensure the accuracy of clinical paperwork, analyze medical data to aid healthcare professionals, and instruct personnel on record-keeping practices. They could be employed by healthcare organizations or hospitals.

 

Clinical Documentation Specialist Job Description

Below are the clinical documentation specialist job description examples you can use to develop your resume or write a job description for your employee. Employers can also use it to sieve out job seekers when choosing candidates for interviews.

The duties and responsibilities of a clinical documentation specialist include the following;

  • Use medical language and practice expertise to assess clinical documents.
  • Update medical records and gather medical data from healthcare professionals.
  • Check the correctness of patient medical data and gather any gaps in knowledge.
  • Monitor the documentation of diagnosis, therapies, and follow-ups in medical records.
  • Analyze and put together clinical reports for medical experts and public health authorities.
  • Discuss results and support action, and schedule a meeting with healthcare stakeholders.
  • Ensure that medical records are stored legally and that their content complies with applicable legislation.
  • Teach medical and administrative workers how to maintain proper medical records.
  • Keep up with developments in the clinical documentation sector and modifications to rules.
  • Examine a certain amount of patient files.
  • Check records for detail and appropriate documentation.
  • Enter document requests into a system for medical professionals, experts, and other staff.
  • Take action on unresolved questions or delayed responses from the past.
  • Ensure that the hospital or doctor’s office receives the appropriate Medicare payment.
  • Contact the patient’s insurance provider, if required.
  • Check patient data for correctness and completeness.
  • Make sure there is appropriate paperwork when it is necessary, such as for Medicaid or insurance billing.
  • Monitor patient outcomes to gauge the quality of the services offered.
  • Follow up with medical professionals to finish a patient’s records.
  • Contact insurance providers about concerns about a patient’s file.

 

Qualifications

  • Degree in health information technology, either an associate’s or a bachelor’s.
  • Preference is given to Registered Health Information Technicians (RHIT).
  • Having a Registered Nurse (RN) would be helpful.
  • Knowledge of Electronic Medical Record (EMR) programs like Praxis and Clinical Works.
  • A minimum of three years in a comparable position.
  • Advanced expertise in medical record-keeping best practices.
  • Comprehensive understanding of medical processes, codes, and terminology.
  • Extensive expertise in staff training and the gathering and interpretation of medical data.
  • The capacity to stay up to date on developments and rules regarding clinical documentation.
  • Excellent communication and organizing abilities.

 

Essential Skills

  • Internal Standards: When evaluating a patient’s treatment, clinical documentation experts apply internal criteria. To ascertain if a course of therapy was successful and upheld all requirements established by a corporation or organization, they may examine medical records. This guarantees that patients get the finest treatment possible and enables clinical documentation professionals to verify that the care being provided by their employers is of a high caliber.
  • System for Coding and Payment by 3M: Medical providers must submit claims to insurance companies by a set of regulations known as the coding and reimbursement system. When recording patient care, a clinical documentation expert must comprehend the numerous codes, what they all imply, and how to properly use them. As a result, the healthcare provider will get reimbursement for their services and appropriate billing will be made.
  • Health Terminology: The language used by medical experts to describe patient problems and treatments is known as medical terminology. Clinical documentation experts must be well-versed in medical jargon and record treatment regimens, procedures, and diagnoses. When asking for information or providing documents to other medical experts, medical language also makes it easier for them to communicate.
  • Biology and Anatomy: The study of physiology and anatomy focuses on how the body functions. To effectively record patient information, such as medical history, physical examination findings, and treatment recommendations, clinical documentation professionals need to have a solid understanding of anatomy and physiology. This entails being aware of both the collective functions of the body’s components and their roles.
  • Organization: The capacity of the organization is the capacity to monitor several tasks and files. Clinical documentation experts often need to arrange a wide variety of papers by date, type, or topic. Maintaining order in your records may make it easier for you to discover information quickly and make sure that all pertinent data is captured.
  • Analysis Capabilities: To choose the most effective course of therapy for patients, clinical documentation professionals need to be able to examine data and information. When analyzing patient records, they also use their analytical abilities to make sure that all pertinent data is correct and present. This might include determining if a method was effective or whether any data patterns may need further research.
  • Coding: Coding is the process of allocating a string of numbers to diagnoses, treatments, and medical procedures. This enables medical professionals to look for particular patient data in electronic records. When they make patient charts that include data about treatments, test findings, and other crucial information, clinical documentation professionals apply coding skills.
  • Financial Management: The process through which a business obtains money for its goods or services is known as the revenue cycle. Specialists in clinical documentation who are proficient in revenue cycle management may monitor and document payments, refunds, and other patient account-related activities. By doing this, it is made sure that medical institutions obtain correct billing data and that patients are appropriately charged.
  • Observation of Details: Specialists in clinical documentation must be able to correctly record patient data and treatment regimens. You must have a keen eye for detail to be able to read medical records and comprehend acronyms and abbreviations. Additionally, it allows you to translate medical experts’ notes into a format that may be readily understood by other medical specialists.
  • Solving issues: Having the capacity to recognize and address problems is problem-solving. While working as a clinical documentation professional, you could run across difficulties. For instance, it could be challenging to locate the data required for correct records if you’re using an old system. You can finish your job more quickly if you can figure out these challenges.
  • Pharmacology: Pharmacology is the study of drugs and how they work. To effectively record patient treatment regimens, clinical documentation professionals need to have a thorough understanding of how medications function. When developing treatment regimens, they also employ pharmacology since they need to know which drugs work best for certain illnesses.
  • Infinite Systems: A clinical documentation expert has to be proficient with computer applications. There’s a good chance you’ll need to learn how to use at least one software since the majority of businesses demand their personnel to enter patient information electronically. The most widely used electronic health records system in the US is called Epic Systems, and many businesses utilize it.
  • Communication: The capacity to present knowledge in a manner that others can comprehend is known as communication. Specialists in clinical documentation must be able to converse well with patients, doctors, and other staff members. This calls on them to possess both outstanding verbal and written communication abilities. To make sure that their records are correct and understandable for everyone who has to access them, they also need to be able to clarify complicated medical terms.
  • Disease Mechanisms: A clinical documentation expert must comprehend the patients’ illness processes. This involves comprehending the physical effects of illnesses and the range of potential therapies for each ailment. If a patient has cancer, for instance, you need to know what treatments they’ve taken in the past and which ones would be most successful for them going ahead.
  • Management of time: The capacity to schedule and carry out work in a manner that guarantees you meet deadlines is known as time management. Time management abilities are crucial for clinical documentation specialists since they finish their tasks according to their schedules. This can ensure that insurance companies process claims properly and that is by hospital protocol.

 

How to Become a Clinical Documentation Specialist

  • Complete an undergraduate program: Because companies prefer to recruit licensed nurses and registered health information professionals, students may pursue post-secondary clinical documentation specialist study in either nursing or health information. Many colleges offer associate’s and bachelor’s degree programs geared for aspiring RNs and LPNs; in certain circumstances, prospective nurses may obtain certifications or diplomas instead. Common course subjects include mental health, patient evaluation, and professional ethics. Most curricula incorporate internships or field experiences. Students who are more interested in health information may pursue an associate’s degree in health information technology or a bachelor’s degree in health information management. These programs may address data analysis and informatics, anatomy, physiology, medical terminology, and coding methods. internships are typically part of the curriculum as well. Be careful to get medical coding competence: Employers generally search for documentation professionals with an understanding of multiple coding systems. Students should make sure their chosen school route incorporates coding courses. A CCDS certification or CDI certification will make applicants appealing to recruiting teams.
  • Get licensed or certified: RN or LPN nursing school graduates may qualify for licensure by passing an exam. Likewise, graduates of health information technology associate’s degrees may achieve the American Health Information Management Association’s (AHIMA) Registered Health Information Technician (RHIT) certificate by passing an exam. Earning a bachelor’s degree in health information management may qualify students for accreditation as a Registered Health Information Administrator (RHIA) (RHIA).
  • Gain job experience: Prospective clinical documentation specialists generally require 2-5 years of work experience in nursing or health information administration. According to the BLS, RNs often begin their careers as staff nurses in hospitals or community health settings. Common responsibilities for nurses include acquiring medical histories, evaluating patients, and performing tests. REITs may obtain experience working as medical coders or records technicians in hospitals, physicians’ offices, clinics, or other healthcare settings. These workers manage the security of patients’ records, code medical information, and arrange databases. this operates in several healthcare settings as well; they’re responsible for supervising all patient data and keeping up with current health information requirements.
  • Become a clinical documentation expert: After having enough expertise in nursing or health information, persons may qualify for a job as a clinical documentation expert. These specialists evaluate records for coding correctness, follow up with doctors, and teach medical staff members about current recording procedures.
  • Earn CCDS certification: Clinical documentation professionals may receive voluntary documentation certification via the Association of Clinical Documentation Improvement Specialists. The Certified Clinical Documentation Specialist (CCDS) certificate gives evidence of proficiency in the profession and may lead to career progression. To qualify for the CCDS test, candidates require 1-2 years of professional documentation experience along with college-level study.
  • Maintain your licensing or certification: In most circumstances, a license or certification must be renewed after a specified length of time. For example, RNs frequently renew their licenses every two years, and completion of continuing education classes may be needed. RHIT and RHIA credentials are also valid for two years; RHITs must obtain 20 continuing education units during that period, while RHIAs need to gain 30 continuing education units.

 

Where to work as a Clinical Documentation Specialist

Clinics, hospitals, and doctor’s offices are just a few of the places where clinical documentation specialists work. Even though they often work during normal business hours, they sometimes have to work late into the night or on the weekend to fulfill deadlines. Clinical documentation experts evaluate medical records and code patient data while mostly working at a desk or computer. They could also be expected to travel to other medical institutions to audit medical records or instruct personnel on documentation processes. Clinical documentation experts must be able to pay great attention to detail and have strong organizational abilities since they play a crucial role in the precise documentation of patient care.

 

Clinical Documentation Specialist

In the USA, a clinical documentation specialist makes an average salary of $76,523 per year or $39.24 per hour. Most experienced workers earn up to $93,154 per year, while entry-level positions start at $63,443 annually.

In the UK, a clinical documentation specialist makes an average income of £39,000 a year or £20 per hour. Most experienced professionals earn up to £71,500 per year, while entry-level roles start at £30,000.

In Canada, clinical documentation specialists make an average compensation of $46,500 per year or $23.85 per hour. Most experienced professionals earn up to $70,000 per year, while entry-level roles start at $37,118.

Australia’s national average for clinical documentation specialists is $104,803 per year or $53.75 per hour. Most experienced professionals earn up to $136,500 annually, while entry-level occupations start at $101,383 annually.

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