Sample Job Description for Clinical Documentation Specialist

Given below is a sample job description template for the position of Clinical Documentation Specialist:

Job Title: Clinical Documentation Specialist

Location of the Job: Houston, TX 77030

Years of Experience: 1 to 3 Years

Job Type: Full Time Employee

Education Level: Bachelor’s degree

Job Summary:

The Clinical Documentation Specialist communicates with physicians, case managers, coders, and other health team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients

Duties and Responsibilities:

  • Educates all members of the patient care team on an ongoing basis.
  • Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and medical center outcomes.
  • Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients.
  • Responsible for improving the overall quality and completeness of clinical documentation.

Position Requirements:

  • RHIA, RHIT or CCS required.
  • A minimum of five years of coding experience is preferred.
  • Working knowledge of Medicare reimbursement system and coding structures required.
  • Motivated, organized with excellent interpersonal communication skills, analytical skills, strong facilitation and presentation skills.
  • PC proficiency with Microsoft Word, Excel and 3M Encoder.

Salary: $22.00 – $24.00 Hourly DOE