Clinical Documentation Specialist

Description

Facilitates appropriate clinical documentation for reimbursement, severity of illness and risk of mortality by advising and teaching physicians and other clinical staff. Develops and implements educational plans to communicate the principles and importance of accurate and complete documentation to members of the medical staff. Serves as a resource on documentation requirements and ensures compliance with applicable laws and regulations. Employees in this classification typically analyze, compare and evaluate various courses of action and have the authority to make independent decisions on matters of significance, free from immediate direction, within the scope of their responsibilities. Primary activities and decision making authority are predominantly performed independently affecting business operations to a substantial degree. Under FLSA, this is the exempt job classification for this title. Incumbents in this position must meet the full criteria for exempt status: salary level, salary basis, and duties tests.