Clinical Document Improvement Specialist, Hybrid (KY/IN Residents Only)

The Clinical Documentation Improvement Specialist is a professional nurse accountable for the documentation management of a group of patients. The clinical documentation specialist focuses on safe effective patient care, customer satisfaction and quality outcomes. They are responsible for assisting in maintaining a financially stable department, promoting their own development with an emphasis on evidence based practice and education supported by a Practice Governance framework. Upon admission and concurrently throughout the inpatient stay, the clinical documentation specialist reviews the medical record for documentation that is ambiguous or nonspecific. The clinical documentation specialist proactively engages the physician in discussion to clarify documentation to ensure the inpatient medical record accurately reflects the patient's severity of illness and the intensity of services provided. The clinical documentation specialist collaborates in the application of Core Measures to manage the care of targeted diagnoses within the system's primary service lines.

**This position has the opportunity to be a hybrid position. You will be asked to complete training at a Norton Healthcare facility and must be able to come in for business purposes. Employees in this role must reside in Kentucky or Indiana**

Required:

• Three years in a critical care or medical surgical hospital setting
• Bachelor Degree If education requirement of BSN met, then RN is required. If education requirement of Medical Degree is met, then RN is not required.
• Registered Nurse If education requirement of BSN met, then Registered Nurse (RN) credential is required. If education requirement of Medical Degree is met, then Registered Nurse (RN) credential is not required.

Desired:

• One year in case management and/or clinical documentation management.
• Bachelor Degree; Doctorate Degree
• Certified Clinical Documentation Specialist