Clinical Documentation Specialist-Medical Records-FT-1st shift

Overview

The Clinical Documentation Improvement Specialist (CDIS) implements clinical documentation improvement (CDI) activities in an effort to support accuracy and quality of the patient records and to ensure that coded diagnoses are an accurate reflection of the patient’s clinical status and care. The role of the CDI specialist involves reviewing the medical record documentation and clinical indicators and working with providers to ensure a complete and accurate medical record. An accurate medical record is important for the patient, for continuity of care by the next provider, and to demonstrate high quality care by the physician and the hospital. The CDI Specialist will identify potential gaps in clinical documentation for inpatient and payer populations as directed throughout the hospitalization. He/she will also educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.

Qualifications

Education: At least one of the following is required: BSN, RN, or comparable clinical degree

Experience

• Must possess at least five years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care). Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding considered a plus.
• Prior experience in clinical documentation improvement, ICD coding and MS-DRGs preferred.
• Prior experience educating physicians/providers preferred.
• Previous experience working in a clinical documentation improvement department or as a consultant strongly encouraged.
• Minimum of one-year auditing experience strongly encouraged.
• This individual must possess a comprehensive knowledge of medical terminology, disease processes and clinical competency.
• Candidate must possess excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge is necessary. Prioritization and organizational skills required. Must exhibit the ability to educate members of the healthcare team about clinical documentation. Individual must demonstrate data quality and integrity skills.
• To perform this job successfully, an individual should have strong working knowledge of word processing software, spreadsheet software and reporting software. Also, experience working with encoder software, clinical documentation improvement software and the electronic medical record is preferred
• English is required for both verbal and written communication. Ability to communicate effectively at a high level is required

Licenses/Certificates: At least one of the following is required: BSN, RN, or comparable clinical degree. In addition, the following are highly desired: RHIT, RHIA, CDIP, CCDS, CCS and ICD-10 certification or designation