Clinical Documentation Specialist

There are six (6) positions available for this role. The Clinical Documentation Specialist will be responsible for the concurrent review of medical records to facilitate clinically appropriate documentation of all patient conditions, treatments, and interventions to accurately reflect the reason for admission, conditions present on admission, quality of care, severity of illness, and risk of mortality to support correct coding, reimbursement, and quality initiatives. SPECIFIC SKILLS NEEDED Clinical experience with an Acute Care Inpatient background in Critical Care or Emergency Department.

with criteria-based chart review, such as Case Management, Utilization management, Managed Care, and Quality Improvement.

Knowledge of ICD-10, the MS-DRG structure, HAC’s, PSI’s, value-based purchasing, bundled payments, accountable care organizations and readmission reduction programs.

Ability to reference and interpret CMS guidelines and regulatory requirements.

Must work independently in performing duties with minimal supervision with a high degree of self-motivation.

Critical thinking, creative problem solving, and conflict management skills.

Extensive knowledge of pharmacology and pathophysiology and disease processes.

Computer savvy: Microsoft Office/Suite proficient.

Excellent verbal communication skills for face-to-face interactions with physicians, to foster relationships of clinical skills and information sharing.

Ability to write queries that are compliant, concise, and easily understood by the provider to garner additional information and clarification of documentation.

Ability to develop and maintain supportive, collaborative relationships with physicians, coders, and other clinical professionals.

Strong attention to detail: highly organized.

EDUCATION/EXPERIENCE/TRAINING Required:

• Graduation from an accredited School in Nursing with BSN
• Valid RN Compact License or International Physician Medical graduate
• A minimum of 3-5 years’ experience in Critical Care or Emergency Department nursing or physician clinical experience
• Minimum 2 years’ experience of CDI Preferred:
• Familiarity with ICD-10 and knowledge of the AHA Coding Clinic.
• CCS, CCDS, or CDIP combined with hospital-based clinical experience.