Documentation Clerk is responsible for clerical duties related to the maintenance of technical documentation. Completes tracking, logging, updating and version control of technical documents according to business standards. Being a Documentation Clerk requires a high school diploma or equivalent. Typically reports to a supervisor. The Documentation Clerk works under the close direction of senior personnel in the functional area. Possesses a moderate understanding of general aspects of the job. May require 0-1 year of general work experience. (Copyright 2024 Salary.com)
The Clinical Documentation Specialist reviews inpatient medical records on a concurrent basis for appropriate documentation and facilitates processes to assure that documentation reflects the care of a patient.
RN preferred; Associates Degree in health care related field required. 4 years recent clinical and coding experience or a DRG Coder with 2 years ICD coding and clinical experience. CCDS (Certified Clinical Documentation Specialist required within 3 years of hire).