RN, Clinical Documentation Specialist

Purpose of Position:

The CDS 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 CDI process is a key role.
• Ability to learn/develop the skills necessary to perform CDI duties.
• 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 the electronic medical record.
• Understand and support clinical documentation strategies.
• Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.

RN, Clinical Documentation Specialist – Grade: NSI4, Job Code: 3057

• Graduate of a School of Nursing
• (RN) - Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts
• (BSN) – A Bachelor of Science in Nursing (external applicants only)
• Minimum of 3 years of current RN, CDI Practice experience
• Must meet at least one of the following qualifications:
  • Certified Clinical Documentation Specialist (CDI)
  • CCHC Clinical Documentation Specialist Exam
• Knowledge of Medicare Part A and Part B
• Knowledge of regulatory environment
• Organizational, analytical, writing and interpersonal skills
• Dependable and self-directed
• Critical thinking, problem solving and deductive reasoning skills
• Knowledge of pathophysiology and disease process
• Basic computer skills – familiarity with Windows based software programs
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers

40 Hours Per Week, Mon-Fri, Rotating Days, 7a-3:30p, Rotating Weekends and Rotating Holidays

Organization : Cape Cod Hospital

Primary Location : Massachusetts-Hyannis

Department : CCH-Care Management

Annual/Hourly: Hourly

Hiring Pay Range: 42.04 - 89.99