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Steps to Develop Yourself into a Qualified Clinical Documentation Specialist

A clinical documentation specialist is also called a medical biller or coder, medical records and health information technician or a medical coding specialist. You can read more about what they do here if you want to become a clinical documentation specialist. Here are the steps of how to develop yourself to a qualified clinical documentation specialist.

Post-secondary certifications take two years. They will also teach your computer systems and database-oriented practices. There are sixty units in the course work of Associate of Applied Science (A.A.S.) program. Some institutions have classes that teach standard office practices and business communication in their programs.

A degree is needed when you need to find a job in consulting firms, public health organizations, pharmaceutical companies and many other healthcare facilities. Most institutions offer HIM or HIT degree programs that incorporate internships or field experiences to develop graduates who have the skills that are needed in the industry. Also, HIT degree is offered in the following colleges; thus, read more about what they do. However, there are independent institutions that do not offer degrees but teach medical coding only hence check them here and read more on what they do.

Refer to Commission on Accreditation for Health Informatics and Information Management’s (CAHIIM) for a master’s degree in HI and HIM and read more about what they do. HIM master’s degree program will teach you administrative issues, information policy, and systems, cost-analysis for issues related to information processing and record maintenance.

You need to know the requirements of your state for one to be certified or licensed as a qualified clinical documentation specialist. You need a professional certification to allow you to explore different certifications before you settle on a specific program. You can take the Clinical Documentation Specialist (CCDS) credential. A clinical documentation specialist likewise needs RHIT certifications to a license. RHIT certification will allow you to join Registered Health Information Administrators (RHIA).

RNs begins as staff nurses in community settings or health centers. RHITs begins as medical coders or records technicians in doctors’ offices, hospitals, clinics and so on. You should also ensure that you keep up with health information regulations that are current when performing your tasks. Your work will be to review records for coding accuracy, inform medical staff members of updates in documentation methods and follow-up with physicians.

These voluntary certifications add value to your CV. You need one to two years of professional documentation experience and college-level coursework for you to qualify to sit for a CDSS exam.

RHIA and RHIT credentials also need to be renewed after every two years through refresher courses. You need to renew your credentials and license so that you are not banned from practicing by the state.

The medical secretary performs clerical tasks like scheduling appointments for patients, answering phones, collecting data on the medical history of the patients and more; hence, read more about what they do. You can get a job as a medical transcriptionist. You need to have a post-secondary training program certification to become a medical transcriptionist; thus, read more about what they do.