Clinical Documentation Specialist- Family Maternity Center (40 hrs/wk, Day)

The Clinical Documentation Specialist for our Family Maternity Center (FMC) specializes in ensuring that the documentation in the patient health record reflects the clinical acuity of the patient. Works in partnership with physicians to ensure clinical information in medical record is present and accurate; and with the Medical Center Coding Staff to support that appropriate clinical severity is captured for the level of service rendered to all patients within a DRG-based payor system.

Reviews Family Maternity Center OB ED and inpatient admissions, as well as newborn and Neonatal Intensive Care Unit (NICU) admissions to identify and improve clinical documentation in the medical record to reflect appropriate severity of illness, risk factors and quality of care provided. Uses a worksheet format to document reviews in order to facilitate reporting and process improvement activities.

Communicates with physicians and coders to ensure accurate and complete documentation in the medical record that reflects the clinical condition of the patient in language that can be coded appropriately.

Performs other duties as assigned.

License, Certification, Education or Experience:

REQUIRED for the position: Current State of Washington RN license, Bachelors of Science degree in Nursing, 5 years of experience as an RN with a minimum of three years of obstetric, postpartum, emergency department or NICU experience. Current Healthcare Provider BLS certification by date of hire, Training in clinical documentation at time of hire or must obtain within three months of hire. Ability to assess, plan, implement and evaluate patient care. Knowledge of the healthcare financial environment, reimbursement and levels of care. Strong verbal and written communication skills Demonstrated ability to work with multidisciplinary teams, and to provide feedback related to clinical documentation to nursing and provider teams.

DESIRED for the position: CCDS certification

To learn more about our Family Maternity Center, please click here.




Full time
Kirkland, WA 98033, US