Clinical Documentation Specialist - Medical Records
St. Peter's Health · Helena, MT, United States ·
- Work mode
- Hybrid
- Employment
- Full time
- Category
- Technical writing
- Experience
- 2+ years
Onsite, Remote, or Hybrid
This position provides concurrent clinical review of inpatient medical records to ensure accurate and complete documentation of diagnoses and procedures. Reviews clinical information, assigns appropriate codes, supports quality assurance and reporting efforts, and provides education to providers and staff on clinical documentation. Requires excellent communication skills, strong attention to detail, and the ability to build positive relationships with physicians while providing guidance in a respectful, non-confrontational manner.
KNOWLEDGE/EXPERIENCE: RN license with at least 3 years of clinical experience highly preferred. 2 years previous clinical documentation experience highly preferred. Clinical Documentation Specialist or Inpatient Coding Certification highly preferred. Strong attention to detail and a high level of accuracy required. Experience may be considered in lieu of certification.
EDUCATION: RN or Healthcare related degree required.
LICENSE/CERTIFICATION/REGISTRY: RN Licensure Required. Clinical Documentation Specialist certification must be obtained within 2 years.