RN, Clinical Documentation Specialist; CDI

Job Description – RN, Clinical Documentation Specialist (CDI)

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

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

Cape Cod Hospital

Massachusetts-Hyannis

CCH-Care Management

Hourly

$ 42.04 - $ 89.99

The pay range displayed on each job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set, and education. This is not inclusive of the value of Cape Cod Healthcare’s benefits package (if applicable), which includes among other benefits, healthcare/dental/vision and retirement.

For annual salaries this is based on full-time employment.