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Clinical Document Specialist

Clinical Documentation Improvement


Address   Franciscan Alliance
    5454 Hohman Ave.
    Hammond, IN 46320

Hours  Days

Calendar  Full-Time

Education Bachelor's Required


Specialized communicators


Clinical documentation sounds a little dry, boring and, frankly, clinical doesn’t it? We can assure you it’s none of those things. In today’s health care world, medical record documentation is a critical component of patient care. The clinical documentation specialist must work with physicians and coding staff to accurately and thoroughly document care. The specialist must also be able to communicate relevant medical knowledge to staff. It’s a job that requires someone with top notch written and verbal communication skills.


Are you a strong communicator? Do you have experience with medical documentation? Are you able to juggle daily tasks that include writing, working with a team, ensuring compliance and evaluating records? If so, we need your skills. 

  • Provide daily clinical evaluation of the medical record documentation by the Medical Staff and healthcare team in accordance with the hospitals designated clinical documentation policies and procedures.
  • Communicate with physicians to ensure accurate and complete documentation is in the medical record. Communication is face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness.
  • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team.
  • Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients. 
  • Provide or coordinate education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG. 
  • Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital's designated clinical documentation system.
  • Gather and analyze information pertinent to documentation findings and outcomes.
  • Identify patterns, trends variances and opportunities to improve documentation review and process.
  • Proficiency in organization and planning.
  • Working knowledge of quality improvement theory and practice.
  • Demonstrate adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice.
  • Knowledge of federal, state and private payer regulations.
  • Experience working with teams and on projects.
  • Excellent interpersonal, organizational, presentation, verbal and written communication abilities.
  • Effective communicator, both orally and in written form, with people at all levels of the organization.
  • Proficient computer and technical skills necessary in order to perform the tasks required, including advanced knowledge of information systems, databases, and spreadsheet applications.




7 Years Acute Care Experience with Minimum 2 Years Recent Inpatient Experience

License(s): Registered Nurse




It is the policy of Franciscan Alliance to provide equal employment to its employees and qualified applicants for employment as otherwise required by an applicable local, state or Federal law.

Franciscan Alliance reserves a Right of Conscience objection in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights.

Franciscan Alliance is committed to equal employment opportunity.

Nearest Major Market: Gary
Nearest Secondary Market: Chicago