RN, Clinical Documentation Specialist; Per Diem

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.

• Extensive record review, interaction with physicians, HIM professionals, and nursing staff.
• Active participation in team meetings and education of staff in the CDMP® process is a key role.
• Ability to learn/develop the skills necessary to perform CDMP®
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible queries
• Effective and appropriate communication with physicians
• Timely follow up on all cases especially those with queries
• Participate in Task Force meetings
• Manage multiple priorities
• Communicates with HIM staff and resolves discrepancies
• Accurate input of data into CDMPTrak®
• Understand and support CDMP® documentation strategies
• 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.

Per Diem, Rotating Days, Shift: 7 AM - 3:30 PM (Hybrid)

Falmouth Hospital Association

Massachusetts-Falmouth

FHA-Care Management

Hourly

40.71 - 78.2