Terrebonne General Health System·Vancouver, British Columbia
Responsible for ensuring that clinical documentation accurately reflects the services and care provided to patients. Acts as a coordinator of physician clinical documentation, coding, and reimbursement processes.
Day (United States of America)
100 - 820000 TG - Hospital Information Management
Responsible for ensuring that clinical documentation within the health system accurately reflects the services and care provided to patients and is consistent with the criteria for high-quality clinical documentation, Acts as a coordinator of physician clinical documentation, coding and reimbursement processes in working towards agreed upon quality and productivity targets for all services in the system. Identifies, monitors, and reports opportunities for quality and performance improvement to the appropriate department. Takes an active role in performance improvement activities as it relates to documentation improvement.
ICD-9CM hospital-based coding experience preferred. Credentialed as an RN, LPN, PA, NP, RHIA, RHIT, or CCS required. Case Management/Utilization review experience preferred. Certification as a CCM, CPHQ preferred. Critical care or strong medical/surgical background required or surgical background if assigned to surgical areas; 3-5 years in clinical practice preferred. Familiar with government healthcare reimbursement systems. Have experience working collaboratively with diverse groups in a healthcare environment. Be successful in interacting effectively with physicians. Basic computer literacy is required; experience with Windows, word processing, spreadsheets, graphics, and databases is preferred. Have the ability to analyze large amounts of data to identify trends. Experience with writing technical reports is desirable.
ICD-9CM hospital-based coding experience is preferred, along with relevant credentials such as RN, LPN, PA, NP, RHIA, RHIT, or CCS. A critical care or strong medical/surgical background is required, along with experience in government healthcare reimbursement systems.
Market context
In British Columbia, Clinical Documentation Specialist roles are typically driven by hospitals and health systems focused on accurate charting, coding quality, and reimbursement compliance. These positions are competitive because employers often look for both clinical experience and coding knowledge, including hospital-based ICD-9-CM familiarity, relevant credentials, and experience with government healthcare reimbursement systems. Review the AI-summarized requirements and benefits on this platform to save research time, then confirm your critical care or medical-surgical background aligns closely with the posting before applying.