Clinical Documentation Specialist

Position: Clinical Documentation Specialist RN

Department: Clinical Documentation

Schedule: Full Time - 40 hours

POSITION SUMMARY:

The Clinical Documentation Specialist (CDS) will provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivery to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

JOB REQUIREMENTS

EDUCATION:

• Bachelor's degree in Nursing or Health Information Management is required; however, an equivalent combination of education and experience, which provides proficiency in the areas of responsibility, may be substituted for the stated education and experience requirements.

• RN or CCS, required. CCDS, CDIP preferred.

EXPERIENCE:

• Minimum 6 years related experience (i.e. 6 years clinical experience including 3 years inpatient case management experience or 6 years of experience inpatient coding with DRG Validation required). Previous CDS experience preferred.

KNOWLEDGE AND SKILLS:

• Knowledge of care delivery documentation systems and related medical record documents.

• Knowledge of age-specific needs and the elements of disease processes and related procedures.

• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.

• Excellent written and verbal communication skills.

• Excellent critical thinking skills.

• Demonstrated employee and medical staff relationships in the past and has the ability to maintain those going forward.

• Working knowledge of inpatient admission criteria.

• Ability to work independently in a time-oriented environment.

• Computer literacy and familiarity with the operation of basic office equipment.

• Assertive personality traits to facilitate ongoing physician communication.

• Ability to be adapt to changes in the workload, to work independently and effectively prioritize work assignments

• Working knowledge of Medicare reimbursement system and coding structures preferred, but not required. IND123

Equal Opportunity Employer/Disabled/Veterans