Clinical Documentation Specialist - Medical Records
St. Peter's Health
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- Location
- Helena, MT
- Job type
- Full time
- Posted
- Oct 2
- 17 days ago
Career path
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About the company
St. Peter's Health
Hospital & health care · 1,001 to 5,000 employees
What you'll do
- Review inpatient medical records for accurate, complete documentation and assign appropriate codes.
- Support quality assurance and reporting, and educate providers and staff on clinical documentation.
What you need
- An RN or healthcare-related degree and RN licensure are required.
- Clinical Documentation Specialist certification must be obtained within 2 years.
Key skills
RN licenseClinical Documentation Specialist certificationInpatient Coding Certificationclinical experienceclinical documentation experiencecommunication skillsattention to detail
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Read the full posting here
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.