Part-time position. Prefer morning hour availability.
Job Title: Clinical Documentation Specialist (CDS)
Department: 7680 Medical Records
Job Function: The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. Active participation in team meetings and education of staff in the Complaint Documentation Management Program (CDMP®) process is a key role.
Job Qualifications:
- Graduation from a program of nursing, BSN preferred.
- ICU experience recommended
- Current state Registered Nurse license
Job Duties and Responsibilities:
- Ability to learn/develop the skills necessary to perform CDMP®
- Accurate and timely record review
- Recognize opportunities for documentation improvement
- Formulate clinically credible documentation clarifications
- Effective and appropriate communication with physicians
- Timely follow up on all cases especially those with clinical documentation clarifications
- Participate in Task Force meetings
- Manage multiple priorities
- Communicates with HIM staff and resolves discrepancies
- Accurate input of data into CDMP Trak®
Skills Required:
- Organizational, analytical, writing and interpersonal skills
- Dependable, self-directed and pleasant
- Critical thinking, problem solving and deductive reasoning skills
- Recent hospital experience preferably in ICU, CCU or strong Med/Surg
- Knowledge of pathophysiology and disease process
- Basic computer skills – familiarity with Windows based software program
- Knowledge of Medicare Part A
- Familiar with Medicare Part B
- Knowledge of regulatory environment
- Understand and support CDMP® documentation strategies
- Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments