Clinical Documentation Specialist

[Layla_B]

Hi everyone,

I am desperately trying to get out of my current Med-Surg position of 4+ years, and I would IDEALLY like to transition into something with less direct patient care. I am a perfectionist, detail-oriented, and very "by the book." I like rules and policies and having the time to devote to being thorough and to think things through. My current job is about as far from healthy for my type of personality as I could imagine.

There is a job posting for a clinical documentation specialist, which I've researched somewhat and it sounds promising. My problem with finding a job is that I over-think everything, and convince myself I am unqualified for every job that is posted based on minor details. If it asks for EKG interpretation skills, which I have, I tell myself I can't apply because I am not confidence that I am "proficient" at the skill as the post asks for, as an example. I need some help determining if this job would be a good fit for me, as stupid as it might sound.

Here is the job posting Qualifications portion:

"Current, unencumbered **** Nursing License. 3-5 years experience as an RN in acute care nursing. Excellent observation skills, analytical and critical thinking, problem solving with good verbal and written communication skills. Knowledge of age specific needs and the elements of disease processes and related procedures for the targeted patient population. Clinical knowledge and understanding of pathology/physiology of disease processes. Strong understanding of medical terminology. Ability to work independently in time sensitive environment. Ability to work as a part of a multidisciplinary team. Ability to assess, evaluate and teach key concepts related to documentation improvement. Excellent time management and projectmanagement skills. Proficiency in computer use and windows based applications. Prefer: BSN. 1 year previous experience as a Clinical Documentation Specialist. Previous experience with ICD-9 Coding Guidelines; electronic health record functionality; supporting software tools for data collection; coding basics & medicare severity diagnostic related groups [ MS-DRG-s], basic information related severity of Illness, risk of mortality, medical necessity, core and quality measures and impact of length of stay."

What do you all think? I have my BSN and, as I said earlier, 4 years of Med-Surg tele. I would never consider myself to be superb at any of the requirements (I have none of the preferred), so that is what's holding me back. I have a basic understanding of pathophysiology as it relates to my job, but it's not like I could write an essay on a given disease process from the cellular level or anything . . . I just want to be excellent at what I do, and getting a job I'm not qualified for and then failing is a terrifying thought.

Thanks for any help!!

[jjjoy, LPN]

Maybe you could at least ask for an informational interview to find out more about this type of position so that you can better determine if it sounds like something you could do and would want to do.

You might even want to go ahead and apply. Of course, their ideal candidate will just be able to walk right into the job and know exactly how everything works. It's a nice ideal, but hiring personnel have to be realistic and if you look like a good fit and like you could learn the ropes quickly, they might be willing to train. Let them decide if they think you have what it takes; no need to decide for them!

It sounds like the kind of position where you'd be reviewing medical records and being involved with coding - that is determining what standardized categories best describe a patient's hospital course based on the documentation. They like clinicians to so this review because non-clinicians may have a harder time interpreting the medical records. Reimbursement relies upon accurate coding. You'd be spending your time with computers and medical records, not patients.

From the way you describe yourself, this seems like it might be up your alley. At least find out more!