RN, Clinical Documentation Specialist; Per Diem

Purpose of Position :
The Clinical Documentation Specialist is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation.

• 1. Extensive record review, interaction with physicians, HIM professionals, and nursing staff.
• 2. Active participation in team meetings and education of staff in the CDMP® process is a key role.
• 3. Ability to learn/develop the skills necessary to perform CDMP®
• 4. Accurate and timely record review
• 5. Recognize opportunities for documentation improvement
• 6. Formulate clinically credible queries
• 7. Effective and appropriate communication with physicians
• 8. Timely follow up on all cases especially those with queries
• 9. Participate in Task Force meetings
• 10. Manage multiple priorities
• 11. Communicates with HIM staff and resolves discrepancies
• 12. Accurate input of data into CDMPTrak®
• 13. Understand and support CDMP® documentation strategies
• 14. Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Falmouth Hospital’s commitment to CARES: compassion, accountability, respect, excellence and service.

• Organizational, analytical, writing and interpersonal skills
• Dependable and self directed.
• Critical thinking, problem solving and deductive reasoning skills
• Recent acute care experience required, preferably ICU, CCU, or strong Medical/Surgical; or acute care case management experience within the last four (4) years.
• Knowledge of pathophysiology and disease process
• Basic computer skills – familiarity with Windows based software programs
• Knowledge of Medicare Part A and Part
  
  B.
• Knowledge of regulatory environment
• Graduation from a program of nursing
• Bachelor of Science in Nursing preferred (external applicants only)
• Current Massachusetts Registered Nurse license
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers
• Management/supervisory experience preferred
• Must successfully pass the JATA exam or equivalent clinical assessment exam.

Falmouth Hospital Association

Massachusetts-Falmouth

Department : FHA-Care Management

Annual/Hourly :
Hourly

Hiring Pay Range : $ 40.71 - $ 78.2